By akademiotoelektronik, 28/03/2023

The man who breathed too much | Brain & Psycho

An electronics specialist specializing in control circuits for electric motors, Michel works in a start-up he co-founded, which produces and distributes small drones. He is a 32 year old young man, in great shape. Finally... in great shape, until two or three years ago: he didn't smoke, never got sick, practiced multiple sports - triathlon, climbing, skydiving, mountain biking, until the day when everything fell apart. out of order. Efforts that he used to accomplish without difficulty have become difficult, painful. Michael has trouble breathing. Difficulties that only worsened and first forced him to reduce his physical activities, until he had to give them up completely.

The tests reveal nothing

When his breathing difficulties started, Michel didn't really pay attention. But after a while, under pressure from his friends, he ended up consulting. His general practitioner did not detect any anomaly and referred him to a cardiologist, for the sake of conscience. This is where the examinations are linked: blood test, cardiac ultrasound, cycloergometer (a bicycle stuffed with electronics intended to analyze the reaction to the effort). But everything is normal! At least Michel's difficulties do not come from the heart...

Then begins another cycle of consultations, this time with pulmonologists: X-ray of the lungs, measurement of respiratory capacity, test to detect possible asthma... But there again, white cabbage. Everything is normal – the physiological values ​​measured at Michel are even above average.

But then, if the problem comes neither from the heart nor from the lungs, what could it be? The question is all the more important as the symptoms only worsen. They are becoming more and more disabling and anxiety-provoking, frustrating... Now, Michel's breathing no longer only makes him suffer during exercise, but even when resting! Hence obviously a psychological suffering: having trouble breathing is very difficult to live with... Sometimes, the mere prospect of having an effort to make causes anxiety and shortness of breath. And then, faced with the increasingly dubious and skeptical gaze that the doctors throw at him, Michel has the impression that we don't understand him, that we don't believe him, that we reject him. Finally, one of them said to him one day: “You should see a shrink. Michel comes out shocked.

Chronic hyperventilation!

It is at this stage of his development that we receive Michel in our department. Very quickly, the doctor who receives him notes the presence of particular symptoms: frequent sighs, dizziness... Which puts a flea in his ear and encourages him to give the patient a so-called "Nimèges" questionnaire, then a test. of hyperventilation. The goal is to further assess how the patient is breathing. And the results are not long in coming. Seeing them, the doctor told his patient: "You most certainly suffer from what is called chronic hyperventilation syndrome. In other words, Michel "breathes too much"!

Although it has many variations, this syndrome typically combines abnormal shortness of breath, measurable abnormalities in breathing (too rapid, too full or too irregular, punctuated by very frequent sighs) and various other symptoms (dizziness, nausea , chest tightness). Often, there is also a "hypocapnia", that is to say a too low quantity of carbon dioxide in the blood (measured by a sample in an artery or by analyzing the exhaled air). By breathing too hard, the patient evacuates this gas excessively, causing chemical imbalances in the blood, themselves causing a change in nervous excitability; a number of symptoms follow, such as tingling or dizziness. In some cases, the symptoms are absent at rest, but occur at the slightest effort or the first emotion...

When the cortex loses it

It remains to be seen why Michel suddenly began to chronically hyperventilate. For the moment, the causes of this syndrome are unknown and we are reduced to hypotheses. When we breathe, many things happen in our body. Muscles contract. Joints move. The lungs inflate. Air passes through the nose. All these phenomena generate messages that are sent to the brain – and in particular to its external part, the cortex. Fortunately, the latter, faced with these normal and very similar messages from one respiratory cycle to another, decides to forget them. This is called "filtering".

In chronic hyperventilation syndrome, the patient's brain may no longer be able to filter this information and the breathing may constantly "disturb" it and attract its attention. It would "interpret" these signals as a problem, and the cortex would send the order to breathe more. Normally, this region is not involved in automatic breathing, the one that works without our attention. This function is carried out by the brainstem, located between the base of the brain and the spinal cord, which relies on the carbon dioxide content of the blood to regulate the rate at which the lungs inflate and deflate, without conscious intervention. . Normally, the cortex only intervenes when you want to voluntarily change your breathing rate (during a relaxation exercise, or to take a deep breath of air before diving into the water).

But in people who suffer from chronic hyperventilation, the cortex would be activated wrongly... It would excessively increase the ventilatory command, without it being a conscious and voluntary breathing: in other words, the cortex, usually mobilized to change breathing intentionally, would begin to modify it without the knowledge of the patients, by parasitizing the orders of the brainstem! For example, a functional brain imaging study by Sandy Jack, of Aintree University Hospital, Liverpool, and colleagues detected abnormal respiratory activity in the cortex of patients with chronic hyperventilation. This is then the beginning of a vicious circle: the cortex perceives breathing abnormally and also reacts inappropriately by seeking to amplify it, which generates even more respiratory messages! Moreover, once the patient is asleep, the hyperventilation stops. This is normal: when we sleep, the respiratory analysis and command centers of the cortex turn off and breathing is no longer governed by the brainstem alone.

Mountain climbing accident

How the hell did this all start? Just before his symptoms appeared, Michel suffered a climbing accident in the Aravis massif. As he climbed in the lead, a "clamp" he had just placed in a crack dropped, causing a fall of about ten meters, with several rebounds on the wall. Result: three broken ribs, a big shock to one knee and six weeks of forced inactivity. This fall in the mountains, which caused him both a huge fright and a very real respiratory injury (the broken ribs), looks like the trigger. In some cases, hyperventilation actually begins after a respiratory accident (it can also be pneumonia) or a heart attack (a heart attack, etc.), or even a major stress attack. The other cases have no clearly discernible cause. It is clear that Michel, meanwhile, combines at least two triggering factors. And if the symptoms worsened afterwards, it is because each negative respiratory experience leaves a trace in the brain, adding to the previous one. The cortex remembers having experienced difficulties and goes “on the lookout”, which leads it to detect more and more “problems”. Another vicious circle...

A pathology that is very hard to live with

Once the diagnosis has been made, the first thing to do is to reassure the patient. Admittedly, the chronic hyperventilation syndrome is difficult to live with (a study has even shown that it degrades the quality of life more than severe asthma), but however embarrassing, worrying, disabling it may be, it is not serious in itself and is not a witness to a dangerous disease. It is also useful to explain to the subject the hypotheses concerning the underlying mechanism, to help him understand what is happening to him. As always, caregiver understanding and empathy are essential. There is no validated drug treatment for this syndrome, but respiratory physiotherapy sessions, where we work on awareness and control of breathing, often help to regain some control of our sensations and feelings. respiratory movements. Finally, some doctors recommend gradually resuming physical effort in a very codified and supervised framework (as is done for other chronic respiratory diseases), in particular to reduce the "greedyness" of the muscles in oxygen and thus reduce the ventilatory demand during exercise.

“I will no longer be able to breathe”

Despite this, the care currently available is not sufficient. The future depends on research and the carrying out of therapeutic trials. If the hypotheses presented in this article are correct, it is by acting at the level of the brain, and not of the respiratory system itself, that we will find solutions. Cognitive-behavioral therapies would likely offer a valuable tool for this. As their name suggests, they rest on two pillars. On the one hand, work on behaviors: in Michel's case, it would be interesting to expose himself again, in a gradual way, to physical exercise, in order to reaccustom himself to the associated respiratory sensations. And on the other hand, work on "cognitions", that is to say the ideas and thoughts that accompany suffering. In this type of disorder, patients tend to continually anticipate the anxiety-provoking sensations that may arise: "I won't be able to breathe if I climb these stairs", "I won't be able to catch my breath", "My life is in danger”… Limiting these phenomena of anticipation already brings about a notable improvement in the quality of life.

Cognitive-behavioral therapies are beginning to be used for chronic respiratory diseases. In 2018, psychologist Ingeborg Farver-Vestergaard, from Aarhus University, Denmark, and her colleagues showed that they largely alleviate the psychological distress of patients with chronic obstructive pulmonary disease. They therefore seem effective in limiting respiratory suffering, even if they remain to be tested in the case of hyperventilation syndrome. But with Michel, it's another approach that has delivered astonishing results...

Climber under hypnosis

The approach that we finally proposed to Michel is that of medical hypnosis. By relying on various mental imagery techniques (consisting for example of imagining oneself in a place one loves), the hypnotherapist thus leads the patient to extract himself, temporarily but completely, from his mental and emotional ruminations. on his breathing, of these constant anticipations linked to his parasitic sensations. The objective here is to desensitize the brain and perform a kind of reset.

During the pilot phase of a project under development, Michel engaged in a weekly hypnosis session for five weeks with a pulmonologist specializing in this method, supplemented by training in self-hypnosis. Thanks to this treatment, his condition improved rapidly. He even managed to do a first session on the Issy-les-Moulineaux climbing wall to test himself. And his emotions have experienced a real upturn. Hopefully, more clinical trials will soon validate the effectiveness of medical hypnosis and other “brain-oriented” approaches in this setting. Only then will these treatments become official therapeutic weapons against chronic hyperventilation syndrome. In the meantime, it is a transformed Michel who has resumed the course of his personal and professional life.