Assessment of breathing is an important principle in first aid.  This includes an initial determination of whether or not the person is breathing normally. An elevated respiratory rate can be a normal (physiological) response to day-to-day activities (e.g. exercise), an appropriate response to illness or injury, or at times, it is breathing more than the body’s metabolic requirements (e.g. anxiety / panic attack).^1.

The term hyperventilation is often thought to mean over-breathing due to anxiety, which is common in specific groups of people. However, rather than having a single cause, abnormal breathing may be due to several conditions, many of which are dangerous. Serious conditions that cause breathing difficulties can also make people feel anxious. Insufficient recognition of dangerous conditions is more dangerous than overtreating a panic attack.

This guideline aims to provide guidance on treating panic attacks, whilst ensuring that serious causes of hyperventilation are not missed. It acknowledges that a presumed diagnosis of panic attack is incorrect at least some of the time, and that many of potential causes of hyperventilation cannot be diagnosed in a first aid context.²

In short, if there is any doubt at all about whether the person’s abnormal breathing is caused by hyperventilation or another problem, send for an ambulance.  

Anxiety is a normal and healthy response to danger and threats and is useful when there is a life-threatening situation.  Anxiety has physical effects, and effects on thinking and behaviour.  A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes.  The person often feels that they have to do something urgently (e.g. escape to a safer place).⁵ Panic attacks are common with more than 1 in 10 people experiencing a panic attack at some time in their life.  They may occur more commonly in people who have an anxiety disorder, a common mental health condition in both Australia and New Zealand. However, panic attacks can occur in people with no previous history of anxiety disorder. Panic attacks are only one cause of abnormal breathing and should not be assumed to be the cause of abnormal breathing when other possibilities exist as noted above. 

First aiders and first aid providers should routinely assess respiratory function in people requiring first aid. This may be a global assessment of whether or not the person is breathing normally.

Breathing that is abnormal may be:

• absent
• ineffective
• too slow or too fast
• too shallow or too deep

The measurement of respiratory rate (per minute) is an important first aid assessment.  It is most accurately undertaken by counting the number of times the person’s chest rises and falls over 60 seconds.  The person is usually at rest, not talking and ideally, unaware that their breathing is being observed.⁴

Table 1. Respiratory rate by age

Many of the symptoms and signs of panic attacks (e.g. rapid and/or difficulty breathing, chest pain, dizziness) can be signs of more serious medical conditions.  Any person with a suspected panic attack that does not fully recover within 30 minutes needs further assessment by a health professional. In general, if a person has no identified reason to have a panic attack, it should be presumed that they are suffering a different problem that may be life threatening, and an ambulance should be sent for.

First aiders should consider that any of the following indicates a high respiratory rate is more likely to be caused by a life-threatening disorder than panic attacks:

• occurring in a young child or a person aged more than 65 years
• associated with chest pain or palpitations
• clamminess
• paleness or change in colour.

Examples of life-threatening conditions that can be mistaken for a panic attack include:

• severe asthma
• anaphylaxis
• heart attack
• severe infection or sepsis
• pneumothorax (“punctured lung”)
• heart problems.

If any of these are suspected, send for an ambulance.

Panic attacks are intense, overwhelming and often uncontrollable feelings of anxiety combined with a range of physical symptoms and signs including:

• a sense of overwhelming panic or fear
• thinking you are dying, ‘losing control’ or ‘going mad’
• increased heart rate
• chest pain
• rapid breathing, difficulty breathing (feeling that there is not enough air)
• feeling choked
• excessive perspiration
• dizziness, light-headedness or feeling faint.

The most common age at which people suffer panic attacks is from mid-adolescence to young adulthood.  People aged over 65 years are more likely to suffer a serious illness than to have a new panic attack.

Rapid breathing can lower calcium levels available for normal nerve and muscle function. This may lead to numbness on the face, hands and feet as well as muscle spasms of the fingers and/or hands.  The fingers and wrists may become claw-like with the thumb held stiffly across the palm. 

Other risk factors for panic attacks include the use of alcohol or drugs, and psychological stressors including isolation, fearful or traumatic experiences, low self-esteem and conflict with friends or family members.^6,7   The person may have experienced panic attacks previously.

Features that make panic attack more likely compared to other diagnoses include:

• Symptoms do not interrupt or wake the person from sleep.
• Symptoms occurring suddenly or “out of the blue”.
• The absence of a trigger (e.g. medication or exercise) for the symptoms.
• The person can speak freely, without problems.

Panic attacks reach a peak usually within 10 minutes and usually last for up to 30 minutes.