Recently I saw a teenage girl for a follow-up from the emergency room. She had been lifting a heavy back pack at school when she heard and felt a pop in her shoulder. Although in a lot of pain she thought it would get better after taking Advil.

 

That night, however, her mom had to take her to the ER. The pain had worsened and she felt that she couldn’t breathe. In the ER X-rays were taken of the chest, shoulder and neck. All were normal. Her neck and shoulder were sore from a pulled muscle but there was no explanation for the trouble breathing. She was to follow-up with her primary doctor.

 

The next day she came to see me. Vital signs were normal and she was sitting comfortably as I gathered the history.

 

But barely touching her shoulder she flinched with exquisite pain. She could move her arm but range of motion was limited because of the pain. There was good grasp and good pulse in that arm. Being concerned about the severity of the pain I questioned if she might need an MRI. She was seen by an Orthopedist that day. He too felt this was all muscular and did NOT warrant any further imaging.
 

Mom brought her back in the next day. Now she felt as if she couldn’t breathe and get air in.

 

This symptom was not addressed in the ER or by the Orthopedist and it was worrying mom. The girl looked anxious but seemed to be breathing comfortably. Her vital signs were normal; her oxygen saturation measured 99%. She had a normal heart exam and her lungs were completely clear. Questioning her in more detail, she stated that pain was shooting down her arm. She felt light headed and dizzy with numbness in her hand and fingers. Piecing this all together, I felt certain that she was hyperventilating .I had her breathe in a brown paper bag for less than a minute. Afterwards she smiled and said that she felt much better. The anxious and worried look had vanished.

 

I told mom that due to the muscle pull she clearly had pain and it was exacerbated by taking a deep breath.

 

To minimize that her body adjusted her breathing to small and shallow breaths without her being aware of this. As a result, over time she inadvertently hyperventilated. Mom asked if anxiety could contribute to this. It most certainly can. The young lady was seeing a psychologist for anxiety and stress. The therapist was recommending that she start a medication for the anxiety. Now things were made clear. As she initially had pain from the muscle pull she began to hyperventilate. This caused other symptoms that were frightening to her amplifying her anxiety and magnifying her symptoms. It was a perfect storm.
 

When we breathe we blow off carbon dioxide and take in oxygen.

 

This maintains a certain amount of oxygen in our blood as well as maintain a stable pH in the blood stream. As one hyperventilates, an excess of carbon dioxide is blown off which alters the pH in the blood stream. This can cause symptoms of hyperventilation which include light headedness, dizziness, chest pain, numbness and tingling of the hands, and even fainting.

 

When one is hyperventilating the symptoms can be reversed by breathing in a paper bag. This allows the person to rebreathe the carbon dioxide which restores the pH back to the normal range, thus alleviating the symptoms.

 

Before using a paper bag for hyperventilation one MUST be certain they are not dealing with some other medical issue. In this girl’s case I knew that she had a normal chest X-ray from the ER. Her vital signs, exam and oxygen saturation were normal as well as a history of anxiety.

 

Mom and my patient were relieved by her dramatic recovery with the rebreathing in a paper bag.

 

They were most comfortable with this diagnosis. She was I instructed to try to do abdominal breathing which would help minimize the hyperventilation. It would also slow her breathing and allow her to focus her attention on it. She was given some relaxation techniques to use when she was feeling anxious. I also told her that if she felt anxious and unable to get air in, she could use the paper bag as a quick remedy. This could be done in a discreet and private manner, even if she was at school, in the restroom etc. I needed to talk to the psychologist about her anxiety for I felt this episode was a combination of her anxiety as well as the muscular pain.