Kussmaul Breathing

Kussmaul Breathing

Also called: Air Hunger, Kussmaul Respiration


Kussmaul breathing is deep, gasp-like breathing that is labored and irregular. It is sometimes referred to as air hunger.

Kussmaul breathing has been linked to metabolic acidosis, a condition where acid levels in the blood are too high. There are several forms of metabolic acidosis, including diabetic ketoacidosis (DKA) and lactic acidosis. The body attempts to correct acidic conditions in the blood through deep breathing. This lowers the amount of carbon dioxide in the body and helps correct irregularities in blood chemistry. In some cases, metabolic acidosis continues to advance and may potentially lead to a coma.

There are several potential causes of metabolic acidosis that can lead to Kussmaul breathing. In patients with diabetes, infections and illness, missed doses of insulin, damaged or spoiled insulin or failure of an insulin pump can lead to DKA and Kussmaul breathing. Kussmaul breathing may also occur as the first symptom experienced by a patient with undiagnosed type 1 diabetes. In patients who do not have diabetes, Kussmaul breathing may be a symptom of kidney or liver failure, alcohol or drug abuse or severe diarrhea.

Kussmaul breathing is a severe symptom that can be effectively treated in a hospital. Patients are usually given intravenous fluids that may include insulin or nutrients to counteract the body’s processing of fats. The liquids also promote urination so the body can rid itself of acids. In some cases, otherchemicals may be given to reduce the acidity of the blood.

About Kussmaul breathing

Kussmaul breathing is a form of hyperventilation. It is characterized by deep, gasp-like breathing that is also described as air hunger. This symptom was named after Adolph Kussmaul, a 19th century German physician who first recognized and described this type of labored breathing. Kussmaul breathing differs from the rapid, shallow breathing of hyperventilation syndromes that are related to anxiety and panic attacks.

Kussmaul breathing is a symptom of metabolic acidosis (a type of acid imbalance in the body). Acidosis simply means that the body is in an acidic (high acid) state. Normally, the body continuously regulates its acid-base (pH) balance. Acids are those substances that increase acidity, and bases are those that neutralize acids and reduce acidity. However, imbalances in pH levels may occur due to illness or disease. There are many causes of metabolic acidosis, including diabetes, kidney disease and diarrhea.

Among people with diabetes, Kussmaul breathing occurs most commonly during diabetic ketoacidosis (DKA). During DKA, the body lacks insulin to break down glucose (blood sugar) in the bloodstream for energy. Instead, it begins to break down fats, which produces acidic waste products in the blood called ketones.

Kussmaul breathing occurs during metabolic acidosis as a way to alter blood chemistry, helping to temporarily stabilize acid levels in the body. When the blood becomes too acidic, it is unable to effectively carry oxygen and nutrients to the cells of the body. Kussmaul breathing forces increased amounts of oxygen into the lungs, which also increases the amount of carbon dioxide that is exhaled. This decrease in carbon dioxide in the body helps to temporarily lower blood acid levels.

Initially, Kussmaul breathing may be fast, deep and labored, becoming slower and deeper as conditions in the body change. Kussmaul breathing that is severe or prolonged may be life-threatening and should be considered an emergency. Patients experiencing any type of breathing difficulty should seek immediate medical attention.

Kussmaul breathing usually occurs during DKA with type 1 diabetes. In some cases, the diabetes is diagnosed because of DKA with Kussmaul breathing. In other cases, Kussmaul breathing occurs when insulin dosage is missed or otherwise out of control due to pregnancy, infection or trauma.

Other symptoms related to Kussmaul breathing

Kussmaul breathing is the primary symptom of metabolic acidosis,a type of acid imbalance in the body. Confusion and fatigue may sometimes occur along with Kussmaul breathing.

Additional symptoms that may occur with Kussmaul breathing are generally those of its cause. For people with diabetes, Kussmaul breathing usually occurs during diabetic ketoacidosis (DKA).

Signs and symptoms of DKA that may accompany Kussmaul breathing include:

  • High levels of glucose (blood sugar)
  • Higher-than-normal levels of ketones in urine (ketosis)
  • Polyuria (excessive urination)
  • Polydipsia (excessive thirst)
  • Polyphagia (excessive hunger)
  • Nausea and vomiting
  • Abdominal pain
  • Fruity-smelling breath
  • Signs of dehydration (e.g., low blood pressure, rapid heart rate)
  • Changes in level of consciousness  

In addition to the above, small children with DKA may also experience headaches and cerebral edema (swelling of the brain). Polyuria in small children may appear as bedwetting.

Potential causes of Kussmaul breathing

Kussmaul breathing is commonly associated with various types of a chemical imbalance called metabolic acidosis. Among people with diabetes, Kussmaul breathing most often occurs with diabetic ketoacidosis (DKA). When the body lacks insulin and cannot use glucose for energy, it begins to break down fats to use for energy, producing a toxic waste product called ketones. Ketones raise the acidity of the blood, which may cause metabolic acidosis and Kussmaul breathing.

Several other conditions may cause metabolic acidosis and Kussmaul breathing. They include:

  • Excessive lactic acid. Lactic acid is a byproduct of metabolism and is present in blood and muscle tissue of the body. Lactic acidosis (a buildup of lactic acid in the body) is a type of metabolic acidosis that can have a variety of causes, including lack of oxygen (e.g., during shock), extensive exercise, seizures, low blood sugar (hypoglycemia), certain medications and liver failure. This condition can cause patients to experience Kussmaul breathing.
  • Kidney or liver disease. The kidneys and liver filter and remove potentially harmful chemicals and waste products from the body. When these organs fail to function properly, acid may build up in the blood. Distal renal tubular acidosis and proximal renal tubular acidosis are two types of metabolic acidosis caused by kidney problems.
  • Severe diarrhea. During severe diarrhea, patients may lose fluids, nutrients and certain chemicals that help neutralize acids in the blood. When this loss is significant, it can lead to increased acidity of the blood. For example, hyperchloremic acidosis is a type of metabolic acidosis that can occur during severe bouts of diarrhea.
  • Alcohol abuse. Blood acidity may be elevated in patients who drink excessive amounts of alcohol and who experience malnutrition or severe vomiting that may occur in conjunction with alcohol abuse or sudden withdrawal of alcohol. Alcoholic ketoacidosis occurs due to a combination of factors, such as an increase in ketones in the body (due to periods of prolonged starvation, when the body burns fat instead of glucose for energy), dehydration (due to vomiting) and the consumption of ethanol, a chemical substance in alcohol that is toxic when consumed in excessive amounts.
  • Drugs, medications, toxins. Metabolic acidosis that occurs due to illicit drug use or medication overdose (e.g., excessive aspirin use). Certain chemicals may directly introduce acids into the bloodstream or interfere with the kidneys’ ability to remove acids from the body. This type of metabolic acidosis may also occur due to the ingestion of toxic substances (e.g., antifreeze). In some cases, prescription medications may increase blood acidity as a side effect.
  • Severe dehydration. When dehydration slows blood flow, it can impair the normal balancing of acid-base levels in the blood, and may cause metabolic acidosis.
  • Sepsis (infection in the blood). When sepsis occurs, blood pressure may decrease significantly, and a patient may go into shock. Major organs may not be able to function normally, increasing blood acid levels among other consequences. This is a life-threatening condition.

Treatment/prevention of Kussmaul breathing

Kussmaul breathing is treated by addressing the underlying cause of the symptom. For people with diabetes, the cause is usually diabetic ketoacidosis (DKA). DKA is a medical emergency typically treated in a hospital. Intravenous fluids and insulin may be administered to help balance a patient’s acid-base (pH) levels. Patients may remain hospitalized for several days.  

Treatment methods for other causes of metabolic acidosis may include:

  • Fluid administration. Increasing the amount of fluids in the body is useful in some patients with the type of metabolic acidosis known as alcoholic ketoacidosis. Fluid increase can also temporarily improve the blood acidity of patients who have experienced dehydration, malnutrition or severe diarrhea.
  • Base or alkali replacement. Certain chemicals (e.g., sodium bicarbonate) may be used to counteract the high levels of acid in the blood. These may be administered intravenously or as oral tablets. However, this type of treatment should be used under the supervision of a physician because it may alter blood acid levels too much or too quickly.

Other possible treatment options include hemodialysis or the use of activated charcoal to remove toxins from the body.

The best way to prevent Kussmaul breathing is to prevent its cause, metabolic acidosis (a type of acid imbalance in the body).  Patients with diabetes should control their glucose (blood sugar) levels, which may help to prevent DKA. Well-monitored insulin dosages can help prevent DKA. In some cases, people with diabetes may need to monitor their ketone levels as well as glucose and insulin levels. This is especially important during illnesses, pregnancy or after a traumatic injury.

Other preventable causes of metabolic acidosis (and Kussmaul breathing) involve drug or alcohol abuse. Medical treatment is available to help those who are addicted to these substances. Physicians and other healthcare professionals associated with abuse treatment programs may help patients avoid substances that may cause metabolic acidosis.

Questions for your doctor

Preparing questions in advance can help patients have more meaningful discussions with healthcare professionals regarding their condition. Patients may wish to ask their doctor the following questions about Kussmaul breathing:

  1. Can you demonstrate what Kussmaul breathing looks and sounds like?
  2. How can you be sure that I am experiencing Kussmaul breathing and not some other type of breathing difficulty?
  3. What do you think is causing my symptoms? Why does this cause breathing problems?
  4. Will you need to perform tests to confirm a diagnosis? How do I prepare for these tests?
  5. What type of metabolic acidosis am I experiencing? How will this affect me?
  6. What will happen if my symptoms become more severe?
  7. At what point should I seek emergency medical attention?
  8. What type of treatment do you recommend for me? What are the risks and benefits associated with this treatment?
  9. For how long will I need to be treated?
  10. What can I do to prevent this from occurring again?
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