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Hyperventilation is associated with a redistribution of peripheral blood lymphocytes
___________-.~~..._.._.,_.-.____.. __ ~__... BRIEF
REPORTS
Hyperventilation Is Associated with a Redistribution of Peripheral Blood Lymphocytes N. A. Mooney, E. D. Cooke, S. A. Bowcock, S. A. Hunt, and B. H. Timmons
Introduction
Methods
It has been suggested that the immune response
Subjects
may be modified by the psychological state of the subject (Dorian et al. 1982), and a number of authors have examined the association between either stress or anxiety and the various parameters of immune function (Jemmott et al. 1983; Baker et al. 1984; Kiescolt-Glaser et al. 1984; Locke et al. 1984). The physiological response to stress incorporates an increase in the rate and the depth of respiration. Chronic symptomatic hyperventilation (CSH) is a condition characterized by ongoing hyperventilation in the absence of an obvious stressor and results in respiratory alkalosis (Bass and Gardner 1984). CSH has been associated with beta-adrenergic stimulation and ongoing anxiety (Magarian 1982). The present study was undertaken in order to determine (1) if there were any apparent differences in the subpopulations of circulating lymphocytes in patients with CSH compared with control subjects and (2) if a brief period of voluntary hyperventilation induced a redistribution of peripheral blood mononuclear cells (PBMC).
From the Department of Medical Electronics IN A.M.. E.D.C S.A.B., S A.H.) and Stress Research Unit (B.H T ). St Bartholomew’s Hospital, London, England. Address reprint requests to Dr. N. A. Mooney. Department of Medical Electronics, St. Bartholomew’s Hospital. West Smithfield. London ECIA 7BE. England. Received March 24, 19x6; revised May 6. lY8h
8 1986 Soaety of Biological
Psychlatr)
Eleven patients in whom a clinical diagnosis of CSH was confirmed by the Hyperventilation Provocation Test were compared with age- and sex-matched control subjects; the ages ranged from 19 to 57 years and 7 of the patients were women. The patients and the control subjects were free of medication known to affect the immune system.
Methods Blood was collected in heparinized tubes, and PBMC were separated on Ficoll-Triosil (Boyum 1968). Baseline PBMC numbers were calculated as the mean number in samples collected 5 and 15 min before the provocation test. Further samples were collected at 5, 15, 30-, and 45min intervals after the start of the Hyperventilation Provocation Test, which has previously been described (Bonn et al. 1984). Endtidal carbon dioxide was monitored throughout the period of hyperventilation. Anti-T and antiB cell antibodies (Leu-2a, 3a, and 12; Becton Dickinson) were used to enumerate proportions of circulating lymphocytes in an indirect immunofluorescent assay.
Statistical Analysis Multiple linear regression analysis and a MannWhitney U test were used to compare the num0(x)6-32231861%03.50
BIOL PSYCHIATRY 1986;21:1324-1326
Brief Reports
1325
There were no significant changes in white cell counts, lymphocyte counts, or in proportions of Th or B lymphocytes in the patient and control group either before or after hyperventilation .
bers of peripheral lymphocytes in samples from patients and the control group at varying time intervals.
Results The proportion of T-suppressor cells was significantly higher in the patient group than in the control group 45 min after the start of hyperventilation @ < 0.0312, Mann-Whitney U test). Throughout the entire period of monitoring, the T cell helper:suppressor (T,:T,) ratio was significantly lower in the CSH group than in the control subjects (Figure l)(p < 0.05, linear regression analysis) and the difference between the ratios was most marked 30 min after the provocation test began (p < 0.053 1, MannWhitney U test). The most marked change in the T,:T, ratio of the control group occurred between 30 and 45 min after the start of hyperventilation, although this change was not statistically significant (p < 0.0690, Mann-Whitney U test).
Discussion This study suggests that a short period of hyperventilation is associated with a subsequent increase in the proportion of peripheral T, lymphocytes in patients with CSH when compared with a control group. The decreased T,:T, ratio in subjects with CSH may be due to the redistribution of T, cells into the peripheral blood. It has been suggested that hyperventilation is a response to beta-adrenergic activation and may become “self-perpetuating” (Hibbert 1984) as the unpleasant symptoms of hyperventilation lead to further anxiety. A previous study has described an enrichment of peripheral T, cells following a short period of beta-adrenergic activation (Landmann et al. 1984a), and a higher
Controlgroup Hyperventilators
0
Figure 1. Proportions of T-helper and T-suppressor lymphocytes before and after hyperventilation in control subjects and in patients with hyperventilation.
30
% T-suppressor
20
2.75 Th T-s
Baseline
5
15 Time
after
30 hyperventilation
45 (mins)
affinity for a beta-adrenergic antagonist has been reported for T, cells than for T,, cells (Landmann et al. l984b). Our results support the proposed role of beta-adrener~i~ a~tivati~~n during hyperventilation. but do not suggest a continuous hyperadrenergic state in patients with CSI1, as the numbers and proportions of T, lymphocytes in the baseline samples from patients and controls were not s~~ni~cantly different. Different subpopulations of PBMC have been reported as the “targets” for the effects of episodes of psychological stress and/or anxiety on the immune response. including the T-helper (Baker et al. 1985). monocyte, and B lymphocytes (L.andmann et al. 1984a) and natural killer cells (Kiescolt-Glaser et al. 1984; Locke et al. 1984). Only one lymphocyte subp~~pulation was changed after hyperventi~ation~ this may be due to a direct effect on T, lymphocytes. Changes in PBMC subpopulations following physical stress differ from those following
psychological
{Landmann
suggesting
et al.
1%4a).
stress that the
susceptibility of any one SUb~pU~ti~)U of PBMC may be dependent on both the nature and duration of the stress and the subsequent neuroendocrine events. As a depressed T,,:T, ratio is in(~~~ative of immunological incompetence. it seems that patients with CSH may become immunologically compromised if their episodes of overbreathing are sufficiently frequent. As far as we are aware. the T, ceil has not previously been described as a target of stress effects induced by chronic hyperventilation.
Baker GHB, lrani MS. Byrom NA. Nagvckar NM Wood RJ. Hobbs JR, Brcwcrton DA ( i 985): Strcs<. cortisol concentrations, and iymphocytc subpop uiations. Hr Mrti .I X0: 1307 Bass C‘. Gardner W t IYXJ): The hyperventilation tiromc. Ctrrdiol PrckY 2:27 34
\>n
Bonn JA. Readhead C. ‘Timmons B I 1984): Enhanced adaptive hehaviour response in agoraphobic patients pretreated with breathing retraining. LLrrtc~r ii56S-669 Boyum A ( 1968): Separation of ieucocytcs from blood and bone marrow. S’ctmrl .I C(in Llrh Invest Z I isuppi 97):77. Dorian B, Garfinkef P, Brown G, Shore A. Giadman D. Keystone E f 1982): Aberrations in lymphocyte \ubpopuiations and function during psychological stress. Clin E.-q7Immunol SO:i?2-138. Hibbert GA (1984): Hy~rventilati~~n as a cause oi panic attacks. Rr Med J 288:263-X4. Jemmott JB, Borysenko JZ, Borysenko M. McClelland DC. Chapman R, Meyer D, Benson H t 1983): Academic stress, power motivation, and decrcaxc in secretion rate of salivary secretory ~lt~lnunog~obuiin A. LU~Z(YJ~ ii: l4~)-14~2. Kicscolt-Giaser JK. Garner W. Speicher C. Penn GM. Holiiday J. Giaser R ( 1984): Psychosocial moditicrs of immunocompetencc in medical students. ~~~~(,ho,~~)i?r Mrd
36:7--
1.1.
Landmann RMA. Mutter FB. Perini CH, Wesp M, Emc P. Buhler FR ( i984a): Changes of immunoregulatory ceils induced by psychological and physical stress: Relationship to plasma catechnlamines. CiUt E.rp iin~~ulf~~/ 58: i27- 135. Landmann RMA. Burgisacr E. Wesp M, Buhtcr FK f 1984b): Beta-adrenergic receptors are different in subpopulations of human circulating iymphocytcz. .I Rrcept Res 1:37-Y).
References
Locke SE, Kraus L. Lcscrman J. Hurst MW. Heisei S. Williams KM (1984): Life change stress. psychiatric symptoms and natural killer cell activity
Baker CiHB, Byrom NA, lrani MS, Brewerton DA, Hobbs JR, Wood RJ, Nagvekar NM (1984): Stress, cortisol. and lymphocyte subpopuiations. Lam-et i:574.
Magarian GJ ( 1982): Hyperventilation syndromea: Infrequently recognized common expressions of’ anxiety and Stress. ~~di~~~~ 61219-236.
I’swhosom
Med 46:44
i-453.
REPORTS
Hyperventilation Is Associated with a Redistribution of Peripheral Blood Lymphocytes N. A. Mooney, E. D. Cooke, S. A. Bowcock, S. A. Hunt, and B. H. Timmons
Introduction
Methods
It has been suggested that the immune response
Subjects
may be modified by the psychological state of the subject (Dorian et al. 1982), and a number of authors have examined the association between either stress or anxiety and the various parameters of immune function (Jemmott et al. 1983; Baker et al. 1984; Kiescolt-Glaser et al. 1984; Locke et al. 1984). The physiological response to stress incorporates an increase in the rate and the depth of respiration. Chronic symptomatic hyperventilation (CSH) is a condition characterized by ongoing hyperventilation in the absence of an obvious stressor and results in respiratory alkalosis (Bass and Gardner 1984). CSH has been associated with beta-adrenergic stimulation and ongoing anxiety (Magarian 1982). The present study was undertaken in order to determine (1) if there were any apparent differences in the subpopulations of circulating lymphocytes in patients with CSH compared with control subjects and (2) if a brief period of voluntary hyperventilation induced a redistribution of peripheral blood mononuclear cells (PBMC).
From the Department of Medical Electronics IN A.M.. E.D.C S.A.B., S A.H.) and Stress Research Unit (B.H T ). St Bartholomew’s Hospital, London, England. Address reprint requests to Dr. N. A. Mooney. Department of Medical Electronics, St. Bartholomew’s Hospital. West Smithfield. London ECIA 7BE. England. Received March 24, 19x6; revised May 6. lY8h
8 1986 Soaety of Biological
Psychlatr)
Eleven patients in whom a clinical diagnosis of CSH was confirmed by the Hyperventilation Provocation Test were compared with age- and sex-matched control subjects; the ages ranged from 19 to 57 years and 7 of the patients were women. The patients and the control subjects were free of medication known to affect the immune system.
Methods Blood was collected in heparinized tubes, and PBMC were separated on Ficoll-Triosil (Boyum 1968). Baseline PBMC numbers were calculated as the mean number in samples collected 5 and 15 min before the provocation test. Further samples were collected at 5, 15, 30-, and 45min intervals after the start of the Hyperventilation Provocation Test, which has previously been described (Bonn et al. 1984). Endtidal carbon dioxide was monitored throughout the period of hyperventilation. Anti-T and antiB cell antibodies (Leu-2a, 3a, and 12; Becton Dickinson) were used to enumerate proportions of circulating lymphocytes in an indirect immunofluorescent assay.
Statistical Analysis Multiple linear regression analysis and a MannWhitney U test were used to compare the num0(x)6-32231861%03.50
BIOL PSYCHIATRY 1986;21:1324-1326
Brief Reports
1325
There were no significant changes in white cell counts, lymphocyte counts, or in proportions of Th or B lymphocytes in the patient and control group either before or after hyperventilation .
bers of peripheral lymphocytes in samples from patients and the control group at varying time intervals.
Results The proportion of T-suppressor cells was significantly higher in the patient group than in the control group 45 min after the start of hyperventilation @ < 0.0312, Mann-Whitney U test). Throughout the entire period of monitoring, the T cell helper:suppressor (T,:T,) ratio was significantly lower in the CSH group than in the control subjects (Figure l)(p < 0.05, linear regression analysis) and the difference between the ratios was most marked 30 min after the provocation test began (p < 0.053 1, MannWhitney U test). The most marked change in the T,:T, ratio of the control group occurred between 30 and 45 min after the start of hyperventilation, although this change was not statistically significant (p < 0.0690, Mann-Whitney U test).
Discussion This study suggests that a short period of hyperventilation is associated with a subsequent increase in the proportion of peripheral T, lymphocytes in patients with CSH when compared with a control group. The decreased T,:T, ratio in subjects with CSH may be due to the redistribution of T, cells into the peripheral blood. It has been suggested that hyperventilation is a response to beta-adrenergic activation and may become “self-perpetuating” (Hibbert 1984) as the unpleasant symptoms of hyperventilation lead to further anxiety. A previous study has described an enrichment of peripheral T, cells following a short period of beta-adrenergic activation (Landmann et al. 1984a), and a higher
Controlgroup Hyperventilators
0
Figure 1. Proportions of T-helper and T-suppressor lymphocytes before and after hyperventilation in control subjects and in patients with hyperventilation.
30
% T-suppressor
20
2.75 Th T-s
Baseline
5
15 Time
after
30 hyperventilation
45 (mins)
affinity for a beta-adrenergic antagonist has been reported for T, cells than for T,, cells (Landmann et al. l984b). Our results support the proposed role of beta-adrener~i~ a~tivati~~n during hyperventilation. but do not suggest a continuous hyperadrenergic state in patients with CSI1, as the numbers and proportions of T, lymphocytes in the baseline samples from patients and controls were not s~~ni~cantly different. Different subpopulations of PBMC have been reported as the “targets” for the effects of episodes of psychological stress and/or anxiety on the immune response. including the T-helper (Baker et al. 1985). monocyte, and B lymphocytes (L.andmann et al. 1984a) and natural killer cells (Kiescolt-Glaser et al. 1984; Locke et al. 1984). Only one lymphocyte subp~~pulation was changed after hyperventi~ation~ this may be due to a direct effect on T, lymphocytes. Changes in PBMC subpopulations following physical stress differ from those following
psychological
{Landmann
suggesting
et al.
1%4a).
stress that the
susceptibility of any one SUb~pU~ti~)U of PBMC may be dependent on both the nature and duration of the stress and the subsequent neuroendocrine events. As a depressed T,,:T, ratio is in(~~~ative of immunological incompetence. it seems that patients with CSH may become immunologically compromised if their episodes of overbreathing are sufficiently frequent. As far as we are aware. the T, ceil has not previously been described as a target of stress effects induced by chronic hyperventilation.
Baker GHB, lrani MS. Byrom NA. Nagvckar NM Wood RJ. Hobbs JR, Brcwcrton DA ( i 985): Strcs<. cortisol concentrations, and iymphocytc subpop uiations. Hr Mrti .I X0: 1307 Bass C‘. Gardner W t IYXJ): The hyperventilation tiromc. Ctrrdiol PrckY 2:27 34
\>n
Bonn JA. Readhead C. ‘Timmons B I 1984): Enhanced adaptive hehaviour response in agoraphobic patients pretreated with breathing retraining. LLrrtc~r ii56S-669 Boyum A ( 1968): Separation of ieucocytcs from blood and bone marrow. S’ctmrl .I C(in Llrh Invest Z I isuppi 97):77. Dorian B, Garfinkef P, Brown G, Shore A. Giadman D. Keystone E f 1982): Aberrations in lymphocyte \ubpopuiations and function during psychological stress. Clin E.-q7Immunol SO:i?2-138. Hibbert GA (1984): Hy~rventilati~~n as a cause oi panic attacks. Rr Med J 288:263-X4. Jemmott JB, Borysenko JZ, Borysenko M. McClelland DC. Chapman R, Meyer D, Benson H t 1983): Academic stress, power motivation, and decrcaxc in secretion rate of salivary secretory ~lt~lnunog~obuiin A. LU~Z(YJ~ ii: l4~)-14~2. Kicscolt-Giaser JK. Garner W. Speicher C. Penn GM. Holiiday J. Giaser R ( 1984): Psychosocial moditicrs of immunocompetencc in medical students. ~~~~(,ho,~~)i?r Mrd
36:7--
1.1.
Landmann RMA. Mutter FB. Perini CH, Wesp M, Emc P. Buhler FR ( i984a): Changes of immunoregulatory ceils induced by psychological and physical stress: Relationship to plasma catechnlamines. CiUt E.rp iin~~ulf~~/ 58: i27- 135. Landmann RMA. Burgisacr E. Wesp M, Buhtcr FK f 1984b): Beta-adrenergic receptors are different in subpopulations of human circulating iymphocytcz. .I Rrcept Res 1:37-Y).
References
Locke SE, Kraus L. Lcscrman J. Hurst MW. Heisei S. Williams KM (1984): Life change stress. psychiatric symptoms and natural killer cell activity
Baker CiHB, Byrom NA, lrani MS, Brewerton DA, Hobbs JR, Wood RJ, Nagvekar NM (1984): Stress, cortisol. and lymphocyte subpopuiations. Lam-et i:574.
Magarian GJ ( 1982): Hyperventilation syndromea: Infrequently recognized common expressions of’ anxiety and Stress. ~~di~~~~ 61219-236.
I’swhosom
Med 46:44
i-453.