What If Kraepelin’s Observations Point to Respiratory Pump Failure in Bipolar Attacks ?

In people with healthy lungs, subtle respiratory muscle failure interfering with metabolism would and could lead to extended periods of altered mood, locomotor activity, and altered mental status. What if there are modern treatment options we haven’t considered. We need to monitor resting breathing rate to identify anatomical and functional defects in the chest.

Non Invasive Ventilation [NIV] is a lifesaving therapeutic option, which should be proposed to the vast majority of patients with ARF. However, the benefits of NIV can be obtained only if adequate monitoring of patients is undertaken. The level of monitoring should depend on the severity of respiratory failure and the patient’s general condition and should be enabled by appropriate location of the patient in the most suitable facility, such as the HDU or ICU. Because of the lack of strong scientific evidence concerning the optimal monitoring methods, it is usually left to the discretion of the clinician. Hence, staff experience in NIV is a key factor for success. The basis of monitoring patients treated with NIV is a regular assessment of patient’s clinical status (vital signs; mainly respiratory rate, respiratory muscle effort and level of consciousness) and continuous monitoring of SaO2 and periodic ABG analysis. Taking into account the rapid technical development and accessibility of transcutaneous methods of measurement of PaO2 and PaCO2, we can expect that these techniques will soon become the gold standard. The important step in the course of treatment is the analysis in real time of the ventilatory parameters of the patient (VTE, leak and I:E ratio) provided by the ventilator as respiratory waveforms and numerical data.” How should we monitor patients with acute respiratory failure treated with noninvasive ventilation? Begum Ergan, Jacek Nasiłowski, João Carlos WinckEuropean Respiratory Review 2018 27: 170101; DOI: 10.1183/16000617.0101-2017

Respiratory pump failure is hard to see and hard to diagnose. The patient will often be unaware of the gradual decline in pump muscle function, but if severe enough they will be aware of altered mood, altered locomotor activity and altered mental function.

The easiest clue is the one that Kraepelin found; abnormal breathing rates- too slow in bipolar depression/ too fast and chaotic in mania-in the same patient; due to labile metabolic conditions.

“Non Invasive Ventilation [NIV] and other supportive medical treatments might be a MIND SAVING therapeutic option, which should be proposed to the vast majority of patients with attacks of manic depressive insanity.

Maybe it is time to test this hypothesis in unmedicated patients during depressive bipolar attacks.

Maybe we should at least see if their respiratory rate suggests that airing out the brain and body properly is made harder or not.

Kraepelin would be pleased, I think.

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