I think that there needs to be a change in the way that doctors examine patients

Neurological injuries and conditions can interfere with breathing without the patient or doctor being aware of this. Breathing affects the mind. Hidden breathing problems can inhibit mind. You cannot function when your mind and your breathing is inhibited. This is why it is important to measure minute ventilation at the start of every appointment. I have informally interviewed many patients in the hospitals with serious psychiatric and neurological looking conditions. I have talked to their families. I have found that many of these patients had survived many physical hardships such as difficult births, premature babies, low birth weight babies, a period of seizures, bad injuries due to being hit by a car or bus, near drowning experience, injuries due to violence, fights, being choked, sports injuries [cervical spine, torso, neck], etc..hardships which could have caused hidden injuries to muscles and nerves in the unprotected periphery- affecting the movement of air into and out of the body. I found a greater range of abnormal breathing rates in the neuropsychiatric and neurological population as well [although this could have been exacerbated by medication]. Proper exchange of air in and out of the body is key to the proper function of all the organs, especially the brain.

Our hypothesis is that bipolar patients may have permanent subtle peripheral injury interfering with the mechanical ability of the respiratory muscles to ventilate i.e. to move air in and out of their bodies normally, in states of health. Thus the respiratory system may not be able to effectively respond to minor challenges to ventilation, such as infections [G.I., respiratory], or to exposure to toxins, head injury, malnutrition, vitamin deficiency, especially B group, or iron deficiency [not necessarily to the point of anaemia], blood loss, surgery, or anything else that can further weaken the respiratory voluntary muscles. If this hypothesis is correct, then non invasive evaluation of minute volume [see last post] will unmask the hypercapnic respiratory failure. If this hypothesis is correct, treating the hypercapnic respiratory failure will cure the manic, depressed and mixed states of insanity [or extended delirium] and restore normal physical and mental health.

This hypothesis is the extension of Kraepelin’s observations made from his continual measurements of all vital signs in thousands of patients during reversible attacks of depressive insanity and manic insanity,. Kraepelin’s observations suggest that inadequate ventilation due to illness, infection or poor conditions [leading to inadequate food or water, etc..] may have contributed to the patient’s loss of physical and mental health.

Today, due to modern advances in medicine, we understand that Hypercapnia can cause patterns of altered mental status, altered muscle tone and altered voluntary motor responses Hypercapnia can be the result of effects of acute illness on existing, subtle and unknown respiratory muscle weakness.

Disorders of the peripheral nervous system, respiratory muscles, and chest wall lead to an inability to maintain a level of minute ventilation appropriate for the rate of carbon dioxide production. Concomitant hypoxemia and hypercapnia occur. Examples include Guillain-Barré syndrome, muscular dystrophy, myasthenia gravis, severe kyphoscoliosis, and morbid obesity. ” from Which disorders of the peripheral nervous system (PNS), respiratory muscles, and chest wall lead to respiratory failure? Updated: Apr 07, 2020
Author: Ata Murat Kaynar, MD; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM https://www.medscape.com/answers/167981-43844/which-disorders-of-the-peripheral-nervous-system-pns-respiratory-muscles-and-chest-wall-lead-to-respiratory-failure

Just imagine if a patient gets attacks of one of the above conditions on top of already limited ability to ventilate. This is what might be happening to bipolar patients.

In the 1985 version of the Handbook of Hospital Medicine written by P.J. Mitchell and P. Platt et al, junior non specialist doctors were taught to screen for neurological disorders resulting in respiratory pump failure [acquired or congenital] by measuring and monitoring resting minute volume  [this involves counting respirations at rest for one minute and measuring resting tidal volume with a portable spirometer; 

R.R.[f]  times  Tidal volume [Vt] =minute volume [VE].  

Doctors were advised to monitor frequently and to check arterial blood gases if minute volume fell below 4 litres/minute. 

[ A normal minute volume while resting is about 5–8 liters per minute in humans].

This way doctors were able to identify and treat insidious respiratory failure with supportive medical care until the patient recovered from their period of neuromuscular weakness and could once more breath on their own.

Doctors do not seem to do this anymore and psychiatrists [even neurologists] never do this.

Psychiatrists do not ask for a paediatric medical history, even though the severe mental illnesses such as manic depressive insanity and schizophrenia, often start during late adolescence or young adulthood. Children often pass through the biggest period of skeletal growth of their lives on their way to becoming adults and doctors do not even examine how this could impact the anatomy or function of the cervical spine, the neck, the thyroid, the larynx, the respiratory muscles or the chest wall in the full grown adult.

If the patient had a pre-existing respiratory defect or broken breathing [as Paula likes to call it] , then they would possibly be at risk for attacks of delirium [hypo, hyper, mixed locomotor states] – because of illness or injury weakening the skeletal muscular system. It might take such a patient years to heal without supportive medical treatments to fix hypercapnic respiratory failure [if this hypothesis holds water and we think it might- if it is tested carefully].

Acidosis or alkalosis are common in people who are sick. Acidosis or alkalosis cause periods of mental confusion or altered mental status. Respiratory acidosis or alkalosis do not necessarily show up on blood panels and can only be detected by arterial blood gas tests to obtain pH and PCO2. ABG tests are invasive and one has to think of a reason to perform this test. Doctors are terrible at detecting altered mental status at any age in any medical condition so the BEST solution is to measure the ability to ventilate, by obtaining minute volumes to screen for hidden respiratory pump failure affecting mood and cognition adversely .

Obtaining minute volume is fast, easy, non invasive and will tell the non specialist family doctor when ABG’s and supportive critical care are necessary. Once we understand what kind of medical care is needed, treatments might become readily available to outpatients from their own family doctors.

The treatments to try, as I understand the literature, are as follows; removing obstructive secretions, opening the airway [bronchodilators], treating secondary and possibly hidden infection and giving non invasive breathing support. This has to be investigated with care, while we learn what helps and what doesn’t, as these patients are nearer to death than they appear. However, if this hypothesis is correct, respiratory failure can cause huge disability , altered mental status, and poor quality of life for many, many decades before finally killing the patient. Current treatments seem to exacerbate metabolic problems, especially blood sugar, as we are well aware and often do not restore full physical and mental health. How would you like to be half as smart as you were before you got sick?

The next time Paula has altered mental status she wants her doctor to measure her minute volume! She seems barely able to ventilate in states of health it seems. I think that there is a lot we do not know about control of ventilation, especially in a slightly broken body that looks fine, but is prone to delirium.

In fact, Paula wants doctors to measure all of their patients minute volume, as part of their medical investigations. She especially wants doctors to measure the minute volumes of psychiatric patients and of demented patients. Paula wants doctors to study breathing more carefully…breathing, Effects of PCO2 on mental status and altered mental status, the range of ventilation rates and depth, with or without healthy lungs, in health and in illness and in relation to states of delirium or, if this hypothesis is correct, in relation to bipolar states.

It is possible that if these patients have hypercapnia, that their mental status can be improved or even brought back to their old baseline state. The treatments to try, as I understand the literature, is removing obstructive secretions, opening the airway [bronchodilators], treating secondary and possibly hidden infection and giving non invasive breathing support. This has to be investigated with care, as these patients are nearer to death than they appear. However, if this hypothesis is correct, respiratory failure can cause huge disability and altered mental status for many, many decades before finally killing the patient. Current treatments will exacerbate metabolic problems, especially blood sugar, as we are well aware and full physical and mental health may not occur.

It might be that easy, in the 21st Century-with 21st century supportive medical care, to open and support the airway till the person recovers to breath on their own, and hopefully regains their normal mood and mental status. If the dysphoric mood is due to the anguish of dyspnea, then restoring ventilation as much as possible might help more than we think.

This hypothesis needs to be explored.

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