ABSTRACT

CORRESPONDING AUTHOR:
Jyoti Vasantrao Kulkarni,
 7, Bharat Nagar, Opp Indraprastha Enclave,
Jyoti Nagar, Aurangabad,
Maharashtra, pin 431005
E-mail: jyotianil.joshi71@gmail.com

ABSTRACT: BACKGROUND: Hyperventilation syndrome (HVS) also known as irritable Heart, Da Costas syndrome or soldier’s heart is induced by stress. It comprises various symptoms like hyperventilation, breathlessness, Light-headedness, dizziness carpal-pedal spasm, tachycardia and numbness or paraesthesia and unconsciousness1. MATERIAL AND METHOD: Twenty seven years man, driver by occupation was posted for surgical extraction of impacted lower right third molar tooth under local anesthesia. After inferior alveolar nerve block with Lignocaine and Adrenaline he developed giddiness and started hyperventilating himself. He developed light headedness, chest pain, and feeling of compression over chest, tingling in hand and perioral region. It was followed by breathlessness and carpopedal spasm. Surgical procedure was abandoned. Patient was shifted to bed.
 To relieve anxiety & pain intravenous Midazolam and Tramadol was given. Patient was asked to rebreathe through paper bag. Breathlessness was treated by Oxygen supplementation through face mask. Next day he was operated under local anesthesia and intravenous sedation with Midazolam and Fentanyl. CONCLUSION: Intravenous midazolam is effective not only in treating the patient of Hyperventilation syndrome but it also helps to prevent it.
KEY WORDS Intravenous Midazolam, Hyperventilation syndrome, Tramadol

INTRODUCTION: Hyperventilation syndrome (HVS) also known as irritable Heart, Da -Costas syndrome or soldier’s heart is induced by stress or anxiety. It comprises various symptoms like hyperventilation, breathlessness, light-headedness, dizziness, carpal-pedal spasm, tachycardia, numbness or paraesthesia and unconsciousness.1It may be acute or chronic.. It is common in young females; female to male ratio is 7:1 and age 15 to 55 years. Stress leads to hyper adrenergic response. Even though it was reported that vasovagal syncope is the most common emergency, acute hyperventilation syndrome is also known to occur in dentistry. We want to report a case of acute hyperventilation syndrome in a patient posted for surgical extraction of right lower last molar tooth.

CASE REPORT: In dental OPD a 27 year old man, driver by occupation was posted for surgical
extraction of impacted lower right third molar tooth under local anesthesia. Procedure was started after administration of inferior alveolar block with 2ml of 2% lignocaine with adrenaline. Patient was complaining of giddiness & sweating for which he was given supine position. He felt comfortable so procedure was restarted but within few minutes, he started hyperventilating himself. We tried to relieve his anxiety by reassuring him but still hyperventilation was continued. Also he was complaining of light headedness, chest pain, feeling of compression over chest, tingling in hand and perioral region. Surgical procedure was abandoned. Patient was shifted to bed.
On examination he had tachycardia and tachypnea, spo2 was 98%.Intravenous Midazolam 2mg and Tramadol 50 mg was given to relieve anxiety and pain. But still hyperventilation was continued and it was followed by an apneic spells. He developed carpopedal spasm. He was treated with intravenous Midazolam 2mg. followed by Intravenous Calcium gluconate5ml. During apnea he was ventilated with ambo bag and Face mask with oxygen supplementation. He was monitored with pulse oximeter and Cardiac monitor. His ECG was normal. After deep sedation slowly his respiratory pattern became normal in about 15minutes.Patient was admitted to ward and was investigated to rule out ischemic heart disease. His CPK-MB, SGOT and SGPT was normal. No abnormality was detected on ECG and other investigations. Next day surgery was done under sedation Midazolam 2mg andFentanyl100µgm intravenously along with inferior alveolar nerve block with Lignocaine and Adrenaline. Patient was monitored with pulse oximeter
and cardiac monitor. Surgery was uneventful.

DISCUSSION: Hyperventilation syndrome (HVS) is said to be due to extreme anxiety which is common in dentistry. Etiology of HVS is not known but affected person appears to have abnormal respiratory response to stress, Sodium, lactate and other emotional trigger. Systemic causes of HVS include metabolic acidosis, drug intoxication, hyperpnoea, cirrhosis or organic central nervous system disorders.
Hypocapnoea with respiratory alkalosis is common finding secondary to hyperventilation. With decline of 1mm of Hg arterial CO2 tension there is 2% reduction in cerebral perfusion leading to cerebral hypoxia1. Respiratory alkalosis increases affinity of Oxygen to hemoglobin and associated hypophosphatemia impairs generation of 2-3 DPG (diphosphoglycerate), both this leads to reduced availability of Oxygen to tissues1.
Cardiovascular response is related to duration of hyperventilation1. Initially decrease in systemic vascular resistance and blood pressure with tachycardia is present 1. Within four to seven minutes this response is lost. Patient develops coronary vasospasm, coronary insufficiency and chest pain mimics like angina. Dyspnea and chest pain may persist for prolong duration and are not caused by only hypocapnea but also excessive use of thoracic musculature1.
     If not treated patient may develop muscular twitching, carpopedal spasm and tetany due to hypocalcaemia. Pulse oxymetry is normal; ABG shows normal PH, low PaCO2, low HCO3, respiratory alkalosis. ECG shows abnormal lowering or inversion of the T-wave and, less frequently, depression of the ST segment2.
Patient of HVS is treated by termination of the procedures, giving upright position, reassuring him and by breathing Carbon di oxide enriched air. It is advisable to give intramuscular Valium 10mg or intravenous Dormicum 5mg and monitor vital signs.
Drug therapy in patients with HVS is essentially a symptomatic treatment.3 Reassure the patient, terminate procedure, correction of respiratory alkalosis by breathing CO2 enriched air through paper bag or full face mask or hand cupped over face is the definitive treatment1,4.
 To relive anxiety Benzodiazepines are given along with opiates. Beta-adrenergic blockers are useful for removing sympathetically mediated symptoms such as palpitations, trembling, and sweating4. Monoamine oxidase inhibitors may be prescribed in patients with panic anxiety and multiple automatic symptoms3. Clomipramine and imipramine also help to restore Paco2to normal in states of panic.3. Benzodiazepines reduce subjective complaints and treat HVS3,5.
Benzodiazepines are generally used for prevention of HVS2,4.But according to Gregory Magarian anxiolytic or antidepressant medication are not much useful4.While Shigemasa Tomiokaetal found that propophol is not effective in treating HVS, he observed improvement in condition of patient after administration of intravenous Midazolam5.
     A beta-adrenergic blocker, propranolol hydrochloride 1.0 mg, was administered intravenously before the tooth extractions4 may be effective for HVS. It is effective in patients who are extremely sensitive and has increased sympatho-adrenal tone. In these patients propranolol decreases heart rate without causing a depression in blood pressure5. However it should be administered carefully and frequent monitoring of blood pressure, electrocardiography, and cardiac function is necessary4.
We used intravenous Midazolam and Tramadol to relieve anxiety and pain. Patient was operated on next day under sedation and local anesthesia. Aim behind reporting the case is to make all anesthetists aware of 1HVS which is easy to treat but difficult to diagnose. As anxiety or stress is the precipitating factor it is advisable to do the minor dental surgical procedures under sedation to avoid such complications.

CONCLUSION: HVS can be treated by reassurance of patient, termination of procedure, ventilation of patient with CO2 enriched air, anxiolytics and analgesics. If hypoxia is noted Oxygen supplementation is advisable. Intravenous Midazolam is effective in relieving anxiety and all symptoms of HVS. Opioids are preferred to relive pain. To avoid such complications it is advisable to do all minor dental surgical procedures under local anesthesia and conscious sedation.

REFERENCES:
1.     GREGORY J MAGARIAN, DEBORAH A MIDDAUGH & DOUGLA LINZ, Hyperventilation syndrome : A Diagnosis Begging for Recognition, Topics in primary Care medicine May 1983-138-5
2.     PAUL N. YU.; BERNARD J. B. YIM,.; C. ALPHEUS STANFIELD, Hyperventilation Syndrome: Changes in the Electrocardiogram, Blood Gases And Electrolytes during Voluntary Hyperventilation; Possible Mechanisms and Clinical Implications Arch Intern Med. 1959; 103(6):902-913.
3.    JOZEFOWICZ R F; Neurological manifestation of pulmonary disease Neurolclin 1989Aug7(3) 605-16
4.    SHIGEMASA TOMIOKA∗, NOBUYOSHI NAKAJO ;Beta-adrenergic blocker for hyperventilation syndrome in dentistry: A report of three cases; Oral Science International (2011)8; 34– 35
5.    SHIGEMASA TOMIOKA, MASAAKI TAKECHI, NAOHIRO OHSHITA, AND NOBUYOSHI NAKAJO; Propofol Is Not Effective for Hyperventilation Syndrome; anesthesia & analgesia March 2001 vol. 92 no. 3 781-782