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過換気症候群

著者: 小川浩正 東北大学 大学院医学系研究科産業医学分野/東北大学病院 睡眠医療センター

監修: 巽浩一郎 千葉大学 真菌医学研究センター 呼吸器生体制御学研究部門

著者校正/監修レビュー済:2022/11/24
患者向け説明資料

概要・推奨   

  1. 過換気症候群は、器質的障害でなく、機能的に換気が過剰に認められないにもかかわらず、換気が過剰に起こることによりさまざまな症状を呈するものである。
  1. 過換気症候群で認められる症状は、低CO2血症および呼吸性アルカローシスにより説明可能である。
  1. 過換気症候群では、多彩な症状に先行する過換気の存在を問診等で確認することが大事である。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
小川浩正 : 未申告[2022年]
監修:巽浩一郎 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、問診・診察のポイントについて加筆した。
  1. 定期レビューを行い、疾患の除外 について修正を行った。
  1. 定期レビューを行い、治療について加筆した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 過換気症候群とは、器質的障害が認められないにもかかわらず、換気が過剰に起こることによりさまざまな症状を呈する症候群である。過換気により動脈血二酸化炭素分圧が下がり、呼吸性アルカローシスを呈する。
  1. 一般人口の6~11%程度に発症し、女性では男性の2~7倍多くみられる。どの年齢でも発症するが、特に不安感が過度に強い思春期の女性での発症が多い。また、慢性過換気症候群は常に不安感を抱えている女性に多くみられる。
 
  1. 思春期にみられる過換気症候群患者では、喘息に罹患している頻度が高い。(参考文献:[1]
  1. 思春期の喘息患者は、喘息を有していない思春期の患者と比較して、過換気症候群(Nijmegen質問票≧23)の頻度が高い(喘息患者25%:非喘息患者2.5%、オッズ比:11.2)。
 
  1. 救急外来を受診する過換気症候群患者の特徴(参考文献:[2]
  1. 女性(55.4%)
  1. 平均年齢36.5歳、20歳代が最も多い(29.4%)、それに次いで、30歳代
  1. 半数以上が時間外(53.7%)
  1. 症状:不安感fear 95.1%、感覚異常paresthesia 61.5%、めまいdizziness  49.7%
  1. 約3割が、以前にも過換気症状のエピソードあり
  1. 約半数が、心因性反応を含む精神疾患に罹患
問診・診察のポイント  
  1. 呼吸性アルカローシスによる酸素解離曲線左方シフト、電解質異常(血清Ca2+濃度減少など)、脳血流減少などの病態に基づく症状がみられる。
  1. 症状としては、呼吸数増加、口周囲や手足のしびれ、助産婦手位といわれる手の硬直などアルカローシス・血清Ca2+濃度減少の症状を認めることがある。
  1. 過換気症候群はしばしば、不安感やストレスと関係しており、心理的要因が原因と考えられている。呼吸困難、動悸などを訴えることもある。

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文献 

Irene D'Alba, Ines Carloni, Anna Lisa Ferrante, Rosaria Gesuita, Maria Laura Palazzi, Fernando Maria de Benedictis
Hyperventilation syndrome in adolescents with and without asthma.
Pediatr Pulmonol. 2015 Dec;50(12):1184-90. doi: 10.1002/ppul.23145. Epub 2014 Dec 2.
Abstract/Text BACKGROUND: Data on the prevalence of hyperventilation syndrome (HVS) in adolescents are scanty.
OBJECTIVES: To determine the prevalence of HVS in a population of adolescents with and without asthma, and to verify whether HVS was related to asthma activity.
METHODS: A population of adolescents was asked to self-complete a questionnaire, including the Nijmegen questionnaire to assess HVS, and a standardized asthma questionnaire.
RESULTS: Seven hundred and sixty questionnaires were suitable for analysis. One hundred and twenty subjects (15.8%) were classified as asthmatic. Forty-seven subjects (6.2%) had a Nijmegen score ≥ 23, which was suggestive of HVS. Symptoms indicative of HVS were ten times more common in subjects with asthma (25%) than in those without asthma (2.5%). Nijmegen score was significantly higher in subjects with lifetime asthma (P < 0.001), current episodic asthma (P < 0.05) and current active asthma (P < 0.001) than in those with no asthma. In the whole population, girls presented HVS more frequently than boys (P < 0.001). There was a significant effect of gender (females, OR 3.2) and status of asthma (lifetime asthma, OR 11.2; current episodic asthma, OR 8.9; current active asthma, OR 41.5) on the probability of suffering from HVS.
CONCLUSIONS: The prevalence of symptoms indicative of HVS in an unselected population of adolescents was relatively high. Symptoms were more common in girls and in subjects with asthma, and there was a significant effect of asthma activity on the probability of suffering from HVS. Further studies need to be performed in order to validate a screening tool for HVS in both adolescents and asthmatic subjects.

© 2014 Wiley Periodicals, Inc.
PMID 25470247
Carmen Andrea Pfortmueller, Sandra Elisabeth Pauchard-Neuwerth, Alexander Benedikt Leichtle, Georg Martin Fiedler, Aristomenis Konstantinos Exadaktylos, Gregor Lindner
Primary Hyperventilation in the Emergency Department: A First Overview.
PLoS One. 2015 Jun 25;10(6):e0129562. doi: 10.1371/journal.pone.0129562. Epub 2015 Jun 25.
Abstract/Text BACKGROUND: Primary hyperventilation is defined as a state of alveolar ventilation in excess of metabolic requirements, leading to decreased arterial partial pressure of carbon dioxide. The primary aim of this study was to characterise patients diagnosed with primary hyperventilation in the ED.
METHODS: Our retrospective cohort study comprised adult (≥16 years) patients admitted to our ED between 1 January 2006 and 31 December 2012 with the primary diagnosis of primary (=psychogenic) hyperventilation.
RESULTS: A total of 616 patients were eligible for study. Participants were predominantely female (341 [55.4%] female versus 275 [44.6%] male respectively, p <0.01). The mean age was 36.5 years (SD 15.52, range 16-85). Patients in their twenties were the most common age group (181, 29.4%), followed by patients in their thirties (121, 19.6%). Most patients presented at out-of-office hours (331 [53.7%]. The most common symptom was fear (586, 95.1%), followed by paraesthesia (379, 61.5%) and dizziness (306, 49.7%). Almost a third (187, 30.4%) of our patients had previously experienced an episode of hyperventilation and half (311, 50.5%) of patients had a psychiatric co-morbidity.
CONCLUSION: Hyperventilation is a diagnostic chimera with a wide spectrum of symptoms. Patients predominantly are of young age, female sex and often have psychiatric comorbidities. The severity of symptoms accompanied with primary hyperventilation most often needs further work-up to rule out other diagnosis in a mostly young population. In the future, further prospective multicentre studies are needed to evaluate and establish clear diagnostic criteria for primary hyperventilation and possible screening instruments.

PMID 26110771
M E Tavel
Hyperventilation syndrome--hiding behind pseudonyms?
Chest. 1990 Jun;97(6):1285-8.
Abstract/Text
PMID 2189694
R W Evans
Neurologic aspects of hyperventilation syndrome.
Semin Neurol. 1995 Jun;15(2):115-25. doi: 10.1055/s-2008-1041015.
Abstract/Text
PMID 7481131
L C Lum
Hyperventilation syndromes in medicine and psychiatry: a review.
J R Soc Med. 1987 Apr;80(4):229-31.
Abstract/Text
PMID 3295237
H Hornsveld, B Garssen
The low specificity of the Hyperventilation Provocation Test.
J Psychosom Res. 1996 Nov;41(5):435-49.
Abstract/Text The Hyperventilation Provocation Test (HVPT) has become a routine procedure in the diagnosis of hyperventilation syndrome (HVS). During an HVPT the patient voluntarily overbreathes for several minutes to produce hypocapnia. The test is considered positive if the induced symptoms are recognized by the patient as similar to those experienced in daily life. The present study tests the assumption that hypocapnia is the primary trigger for symptoms during an HVPT. In a randomized double-blind crossover design. 115 patients suspected of HVS and 40 healthy controls performed an HVPT and a placebo test (PT, isocapnic overbreathing). The HVPT induced more symptoms than the PT, especially more neuromuscular symptoms, cerebral symptoms, paresthesias, and temperature sensations. However, the absolute difference between the number of symptoms induced by the HVPT and PT was small. In patients, the PT induced 66% of symptoms induced by the HVPT. In the control group this percentage was 60%. The low specificity of the HVPT implies that symptom recognition during the HVPT is invalid as a diagnostic criterion for HVS.

PMID 9032708
H K Hornsveld, B Garssen, M J Dop, P I van Spiegel, J C de Haes
Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome.
Lancet. 1996 Jul 20;348(9021):154-8.
Abstract/Text BACKGROUND: Hyperventilation syndrome (HVS) describes a set of somatic and psychological symptoms thought to result from episodic or chronic hyperventilation. Recognition of symptoms during the hyperventilation provocation test (HVPT) is the most widely used criterion for diagnosis of HVS. We have investigated the validity of the HVPT and of the concept of HVS.
METHODS: In a randomised, double-blind, crossover design, the ability of 115 patients with suspected HVS to recognise symptoms during the HVPT was compared with the ability to recognise symptoms during a placebo test (isocapnic overbreathing, with carbon dioxide levels maintained by manual titration). 30 patients who had positive results on the HVPT underwent ambulatory transcutaneous monitoring of pCO2 to ascertain whether they hyperventilated during spontaneous symptom attacks.
FINDINGS: Of the 115 patients who underwent the HVPT and the placebo test, 85 (74%) reported symptom recognition during the HVPT (positive diagnosis HVS). Of that subset, 56 were also positive on the placebo test (false-positive), and 29 were negative on the placebo test (true-positive). False-positive and true-positive patients did not differ in symptom profile or in physiological variables. During ambulatory monitoring (15 true-positive, 15 false-positive) 22 attacks were registered. Transcutaneous end-tidal, pCO2 decreased during only seven. The decreases were slight and apparently followed the onset of the attack, which suggests that hyperventilation is a consequence rather than a cause of the attack. There were no apparent differences between false-positive and true-positive patients.
INTERPRETATION: The HVPT is invalid as a diagnostic test for HVS. Hyperventilation seems a negligible factor in the experience of spontaneous symptoms. The term HVS should be avoided.

PMID 8684155
J van Dixhoorn, H J Duivenvoorden
Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome.
J Psychosom Res. 1985;29(2):199-206.
Abstract/Text The pattern of complaints of patients with the hyperventilation syndrome (HVS) was studied on the basis of the Nijmegen HVS Questionnaire (van Doorn, Colla, Folgering). This list was completed by 75 patients with the clinical diagnosis HVS. Non-metric principal components analysis (NMPCA) showed that the structure was three-dimensional, the dimensions being labelled: Shortness of breath (HVS-1), Peripheral tetany (HVS-II), Central tetany (HVS-III). The questionnaire's differentiating ability was investigated by comparing HVS patients with non-HVS persons (80 persons employed in health care). All three components had an unequivocally high ability to differentiate between HVS and non-HVS. Application of linear analysis of discriminance to HVS-I, HVS-II and HVS-III together yielded 93% correct classifications. Statistical double cross-validation resulted in 90 and 94% correct classifications. The sensitivity of the Nijmegen Questionnaire in relation to the clinical diagnosis was 91% and the specificity 95%. It is concluded that the questionnaire is suitable as a screening instrument for early detection of HVS, and also as an aid in diagnosis and therapy planning.

PMID 4009520
L L Van De Ven, B J Mouthaan, M J Hoes
Treatment of the hyperventilation syndrome with bisoprolol: a placebo-controlled clinical trial.
J Psychosom Res. 1995 Nov;39(8):1007-13.
Abstract/Text The hyperventilation syndrome (HVS) can be regarded as a form of panic disorder associated with a relative increase in sympathomimetic tone, the effects of which can be counterbalanced by beta-adrenoceptor blockade. The efficacy of the beta-blocker bisoprolol was investigated in a double-blind placebo-controlled randomised crossover trial involving 60 patients from 17 general practices. Following a single-blind placebo prephase, patients who met the inclusion criteria were randomised to treatment with either 5 mg bisoprolol or an identical-looking placebo tablet once daily for three weeks. They were then crossed over to the other treatment arm. At the end of each treatment phase the number of hyperventilation attacks and the severity of symptoms were assessed and side effects recorded. The number of attacks decreased from 4.04 per week at baseline to 3.52 with placebo and to 1.26 with bisoprolol. The decrease of attacks with bisoprolol was significant (p < 0.05) compared to baseline and placebo. The severity of the complaints improved from 29 (scale 0 to 64) at baseline not significantly to 26 with placebo and significantly (p < 0.05) to 15 with bisoprolol. No serious side effects were reported. Five milligrams of bisoprolol once daily is effective and safe in the maintenance of symptom reduction in patients with the hyperventilation syndrome.

PMID 8926595
Abstract/Text It is traditional practice to treat acute hyperventilation (thought to be due to anxiety) by having patients rebreathe into a brown paper bag. The author reports three cases in which this treatment, erroneously applied to patients who were hypoxemic or had myocardial ischemia, resulted in death. This clinical experience motivated a study of the effects of paper bag rebreathing in normal volunteers. Subjects deliberately hyperventilated to an average end-tidal CO2 concentration of 21.6 (SD, 3.2) mm Hg and then continued to hyperventilate into a no. 4 Kraft brown paper bag containing the calibrated sensors for a Hewlett-Packard 47210A capnograph and a Teledyne TED 60J digital oxygen monitor. Fourteen men and six women with an average age of 36 years (SD, 6.1) were tested. Results are reported as mm Hg. After 30 seconds of rebreathing, mean change in O2 from room air was -15.9 (SD, 4.6) and mean CO2 was 38.7 (SD, 6.2); at 60 seconds, -20.5 (6.0) and 40.2 (6.4); at 90 seconds -22 (6.8) and 40.5 (6.4); at 120 seconds -23.6 (6.8) and 40.7 (6.5); at 150 seconds -25.1 (1.2) and 41 (7.3); and at 180 seconds -26.6 (8.4) and 41.3 (7.5). A few subjects achieved CO2 levels as high as 50, but many never reached 40. The mean maximal drop in O2 was 26 (8.8); seven subjects had drops in oxygen of 26 mm Hg at three minutes, four had drops of 34 mm Hg, and one had a drop of 42 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 2499228
K Chin, M Hirai, T Kuriyama, H Kita, T Nakamura, K Shimizu, K Kuno, M Ohi
Hypoxaemia in patients with hyperventilation syndrome.
QJM. 1997 Jul;90(7):477-85.
Abstract/Text We assessed 12 patients with hyperventilation syndrome (HVS) who had experienced hypoxaemia (PaO2 < 60 Torr or SaO2 < 90%) despite the lack of any other organic disease and variability in their blood gas data. Hypoxic and hypercapnic ventilatory responses were measured in nine. Eight of the 12 patients had been referred from other hospitals to our institution for hypoxaemia of unknown origin. Mean PaO2 (n = 12) at rest (non-attack stage) was 87.3 +/- 7.5 Torr (mean +/- SD). Their (n = 9) hypoxic (-0.53 +/- 0.32 l/min/%; range 0.12-0.99) and hypercapnic (2.01 +/- 0.76 l/min/Torr; range 0.69-3.17) ventilatory responses were both within the normal range in our laboratory. The patients with HVS had variable blood gas data, and some of them also exhibited hypercapnia (PaCO2 > 45 Torr). Clinicians who treat patients with HVS should be aware of the possibility of hypoxaemia, even when ventilatory responses are normal. Physicians should also consider HVS as a diagnosis when treating patients with hypoxaemia of unknown origin.

PMID 9302432

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