I am surprised by the lack of research on [permanent] bradypnea in health and in illness. … This is something Kraepelin identified over 100 years ago in his depressed bipolar patients with frequent sleep arousals and insomnia [and brain fog]. My friend Paula also has this and has had it seemingly most of her adult life and she didn’t know and neither did anyone else. She found out in a basic first aid training class. Knowing this about a patient can predict when they might need additional supportive modern medical care to hasten their recovery. Paula is fine, but it would be necessary for doctors to know her baseline minute ventilation should she ever needed a respirator. It is details like this that makes fitting the respiratory to the patient difficult, even dangerous.
In the 1980’s, doctors in England, working in hospital emergency departments used to always measure ventilation; the respiratory rate and the [usual] nonspecific physical signs alerted them to possible neurological emergencies like Guillain-Barre, polio, and other problems with the skeletal-respiratory muscle pump causing respiratory failure and retention of PCO2.
Minute ventilation is easy to measure and is non invasive. It will tell doctors how much air the patient is moving in and out of his/her body [even if their lung function is normal].
I learnt that getting minute ventilation requires 1] counting respirations at rest for one minute with a stopwatch plus 2] evaluating lung function [can now be done with a portable spirometer]. If you multiply these two bits of information you get the minute ventilation. This tells you if the person is exchanging enough air per minute even when their spirometry is normal and their lungs clear. You will not know what you do not measure and the patient will not be aware of this.
We found out accidentally in a basic first aid class [where they taught us to count respiration rate] that my friend Paula had bradypnea, all the time, in health. [and she does not take drugs or meds.] ..She was not aware of her own breathing rate or even that it was unusual . [Breathing rate at rest is handled by the brain stem seamlessly and involuntarily]. Paula even has active exhalation at rest . So normal breathing at rest is an effort for her. She thought everyone breathed like her. [they do not!]
Everyone in our first aid class was surprised that Paula had such slow breathing, since no one can tell by looking at her. And she is fine, fit, normal, happy, good at her job [teacher]…regardless of the bradypnea, but it does seem to put her at risk for [hidden] respiratory pump failure when experiencing the stress of further illness or injury or blood loss or whatever. We forget sometimes that illness is a significant stressor. And we tested her respiratory rate when sick, it does not rise-if anything-it declines slightly to 2.5 breaths per minute. We have measured this with a Hexoskin shirt we bought just to prove it. [It has an embedded respiratory plethysmograph in the shirt.]
Her effortful too slow breathing means that Paula has less respiratory reserve and flexibility when ill or when recovering from illness. It also means that something is broken because she does not seem to be able to raise her breathing rate except through locomotor activity; it seems that this involves a different mechanism. We find this fascinating and worthy of more study.
We learnt that Paula was resuscitated and transfused at birth in 1955, and perhaps her breathing mechanism was affected. However from the time she was brought back to life till today she has thrived. [except for a year and a half twenty years ago when she was pretty sick].
We also learnt from JS Haldane and other early research physiologists that healthy adults have a wide range of respiratory rates, at rest when awake; from as low as 3 breaths per minute [like Paula] to as high as 28-30 breaths per minute [like my nephew]….with healthy lungs.
Paula has always had excellent and normal spirometry results, [or she would be dead by now] but no one measured her minute ventilation. …..
…….. It turns out that she exchanges less than 2 litres of air per minute when healthy and awake...not the 5-8 litres that is considered standard. …..How can that be? . No one knows!. But she is extremely fit! She has to be….biologically. In ways we do not yet understand.
Her breathing rate did not increase with the stress of illness , it remained bradypneic- and I think that she had mild respiratory pump failure. She also had brain fog and had to take leave from her work as a college teacher. [I had read “Bodily Signs” of Kraepelin’s “Manic Depressive Insanity” so I counted her respirations and her blood pressure and her temperature and her heart rate and found pretty much what Kraepelin reported. I found too slow breathing that was not stimulated by the stressor of physical illness. Also, unlike her usual state- her BP was raised, as was her HR, but her body temperature-like her breathing was low. ] Back then, I did not even understand the significance of what I found or what Kraepelin found, but after 20 years of reading undergraduate respiratory physiology, I understand now that she had some kind of mild respiratory failure…[and this despite normal blood tests].
I have learnt that we take compensatory mechanisms for granted and assume that they are intact for dealing with acid-base balance in the blood and for adequate mechanical exchange of air [with normal lung function], but these functions can break down quietly due to illness and injury incurred over a lifetime. And today we have supportive medical treatments for this and are developing more solutions.
But we need a better understanding of who might stand to gain from these innovations…….
Paula spontaneously recovered her physical and mental health after 18 horrible months. ….[Kraepelin’s manic depressive patients had naturally remitting and relapsing episodes too; lasting decades sometimes….and then they also recovered to their normal physical and mental status baseline…without lasting brain injury. ] Paula only experienced the depressive episodes described by Kraepelin. And Kraepelin describes the switch to too fast periodic breathing during manic episodes in the same patients who too had too slow breathing while depressed , ….too fast periodic breathing [with hints of developing heart failure are part of the manic phase of this metabolic syndrome, Too slow breathing with sympathetic activation of everything except for breathing rate describes the phase of depressive insanity.
These are nothing but extended periods of delirium [motor subtypes and all] in people with unlooked for, involuntary – chronically broken breathing mechanisms , in our opinion. And in the 21st century we have effective treatments for respiratory failure, of the hypercapnic kind.
Hidden injuries to the sensors or tissues of the neck, torso etc..can occur and make PCO2 balance more complicated for the brain stem and other structures involved in the complex motor part of moving air in and out of the body. And neither the patient or the doctor will understand what is going on.
I think that there is a lot to learn about permanent bradypnea in patients at rest, and permanent tachypnea in patients and how the body copes nonetheless in health and in illness, sometimes affecting the quality of recovery after an illness or an injury or even surgical interventions.
So this is a medical puzzle, one that very few -other than Kraepelin and thanks to him, myself, are even aware of, much less investigated and understood.
This very same problem of what I call “broken breathing” might explain the disabling neurological symptoms affecting some COV-ID survivors.
Doctors have stopped measuring minute ventilation and are loath to ask for arterial blood gas tests which are painful and invasive. But if one’s mind and quality of life is at stake, maybe we should rethink all of this and investigate what is going on.
There are many treatments for pump failure these days, but they will not be tried if doctors do not suspect it. And the signs will be frustratingly nonspecific, but specific upon getting minute ventilation measurements and , if necessary PCO2 measurements.
These patients will not know that they have an abnormal R.R at rest- this is involuntary. Any hint of sudden altered mental and locomotor status should prompt the doctor to obtain minute ventilation in order to guide the treatment and rescue mental and physical status, no matter what the age of the patient...we should no longer simply neglect getting this evaluation for young adults who suddenly appear with altered mental status;
These patients also do not know that their heightened arousal, distress and anguish is possibly from the respiratory failure they cannot identify. These patients will need a supportive medical boost from their doctors in order to recover to their baseline physical and mental health. And all doctors can learn to do this. It is basic first aid.
Maybe some of our demented patients have hidden chronic bradypnea or tachypnea messing up PCO2 in their blood, causing their mental confusion. How hard would it be to obtain their minute ventilation or arterial blood gas if they are that sick? This is an area begging for this type of investigation, in my opinion.
Respiratory acidosis type 2 and all acid base disorders will cause different syndromes and stages of altered mental status.
We have treatments for this. But not unless we change our medical practice to at least obtain accurate minute ventilation.
At least , measure their vital signs, including their chronic respiratory rate at rest when awake. This will identify [hidden chronic] bradypnea or tachypnea and broken breathing.
And guess what,…. some insomnia is aggravated with [hidden] respiratory failure, or heart failure- despite normal HCO3 and O2.
It is complicated and there is lots more to learn.
I, for one, think that this stuff is fascinating. Even Paula thinks it is cool. [Her doctors do not lol].
I think that you will also find that some cases of “essential hypertension” is a consequence of hidden pump failure and will be difficult to control if you do not address their respiratory insufficiency. Sometimes a raised BP is a response to avoiding further [hidden ] brain injury due to mild suffocation from hidden pump failure.[respiratory or cardiac.]..and they are often linked but again, not always.
I hope that you and your colleagues will think about this.
No one since Kraepelin has investigated this……. [and I do not really count since I am not a doctor or a researcher- just lucky enough to have befriended Paula.
Please think about this…and tell your colleagues to think about it…..biological physical chemistry is really really cool!!!
Of Sound Mind 