Nature’s Clever Trick or ventilatory defect?

Dear doctors, researchers and scientists, [still working on this…..]

Paula grew up in a poor part of Paris in an apartment zoned for commercial use. Her father had a fur coat production workshop in the home and back in 1955 it was common to cook and heat the home with a coke oven if you could afford to.

Paula’s parents had had Rickets when babies and Paula’s Mom’s lower body was deformed.So due to poverty she had difficulty delivering her child, who got stuck too long during birth.  The newborn was born not breathing, swallowed meconium, was resuscitated [hyperoxia] and transfused and miraculously was completely OK thereafter.  She is a healthy 65 year old today.

But, it seems that genes may have been turned off and on, due to her major difficulty transitioning to air and having swallowed meconium.  She has been found to have a minute ventilation of 1.5 L per minute.   Her respiratory rate [RR] at rest when awake is a very stable 3 breaths per minute and her tidal volume is normal at .5 L.  Hence the assumed minute ventilation of 6-8 L is incorrect and shows the importance of measuring respiratory rate as well as tidal volume in adults in health and in illness.  Her RR does NOT increase under the stimulus of infection or physical illness. It increases sluggishly with physical exercise .

Breathing less air per minute seems like a clever way to avoid breathing polluted air and I guess nature has all kinds of evolutionarily- conserved tricks up her sleeve.

How would anyone mechanically ventilate the adult Paula , if she got very sick, without causing her further damage? Wouldn’t it be important to know her baseline vital signs ?

Do unknown, unseen unreported hidden ventilatory defects/injury/adaptations  limiting the ability to move air in and out of the body [with normal lungs]   occur in resuscitated patients or perhaps only in babies?   Are these injuries/adaptations protective?  Are they protective  throughout the different hormonal and physical stages of life? Do they fail with certain hormonal changes throughout the lifespan? Would we even recognize failure of such a system if we encountered it?

Who knows?   Measurements of minute ventilation would be a good start.  And I guess knowing baseline PCO2 in health at rest, in an adult would be useful too. The brain monitors PCO2 so maybe we should too. CO2 in the blood is a natural byproduct of  cell metabolism which we all need to exhale.  This is made physically more difficult [moving air in and out of our bodies] when we are sick, physically weak or frail.

We need to perhaps look at this more closely.

Dr Emile Kraepelin, in the 1900’s did not have spirometry, but he could count respirations of his patients for one full minute. [having a stopwatch helps].Dr. Emile Kraepelin, back in the 1900’s found ventilatory system defects/injuries in thousands of unmedicated manic depressive insanity patients. 

Failure of this system seems to occur around age 25+, especially after physical illness, injury or new chronic exposure to polluted air. [Kraepelin found].

We have treatments for this today.   Paula has the same defect/ described by Kraepelin, .probably as a result of her birth difficulties.  Her depressive episode echoes Kraepelin’s descriptions and so did her physical signs [as recorded and measured by Kraepelin].  We think this is significant.  We think that this needs further study.

Does this apply to Postcovid  patients?  Maybe, maybe not….we think it needs further study.

To summarize what we have been posting…. “Paula has hidden ventilatory system injuries which make acid base regulation more difficult, especially carbon dioxide regulation in the blood.

I do not understand why we had to find out  accidentally,  about Paula’s inability to raise her abnormally slow regular breathing at rest when awake. We found out   accidentally, and only     because we took afirst aid class for work.  Paula’s lung function is normal [for her age] at .5 L per breath.

No one measures respiratory rates at rest in neurology or any branch of medicine.  This despite the complex neural and motor act of breathing involving involving more than healthy lungs to be able to move air in and out of the body, 

 This despite the knowledge that the brain stem regulates the vital signs of RR,BP,HR,and body temperature to maintain homeostasis, especially normal PCO2 levels in the blood. This despite carbon dioxide in the blood being a cerebral vasodilator. This despite the ease of carbon dioxide retention in humans, during illness or exposure to heightened levels of CO2 in poorly ventilated, overcrowded conditions with cheap heating and cooking fuels spewing out more CO2. 

This despite the knowledge that carbon dioxide effects include mental confusion, distress, and even coma. This despite that carbon dioxide is a NORMAL product of cell metabolism and the brain stem and the autonomic nervous system is practiced in dealing with it. This despite the knowledge that carbon dioxide in excess is an intoxicant , a deliriant , and an asphyxiant, depending on abnormal levels in the blood.This despite the knowledge that CO2 effects are reversible   as long as you do not die.

 This despite our modern 21st century tools which can offer brain saving supportive medical care and non invasive breathing support to potentially restore cardiovascular and mental status.  

This hypothesis needs to be explored further.

 I would like to tell you about one baby [Paula] who did not take her first breath at birth, was suctioned [she’d swallowed meconium] and was resuscitated [hyperoxia] and the needed to be transfused [adult blood products?] in 1955, Paris France.  Her name is Paula, and we discovered by accident , that her breathing rate is abnormal although her lungs are healthy.  And she had no idea.  She is 65 today. We converse everyday over coffee [by Zoom, now].  – We also found out that she does not have normal respiratory responses to infection or chemical exposure [to CO2].

Accidental findings can lead researchers to discover things they would never have dreamed possible. ….etc….

I am interested in hidden hypercapnic respiratory failure.

I am not a doctor or a scientist but I have learnt a lot about my friend Paula.  What I learnt may provide clues to the  ongoing cardiovascular and neurological and neuropsychiatric problems post COV-ID. Maybe natural [no yoga, no medications, no drugs] respiratory depression explains ESSENTIAL HYPERTENSION? I will bet you that hypercapnia causes activation of the fight/flight response and will raise blood pressure and heart rate accordingly……and even then ….respiratory depression continues….because something is broken. [sympathetic activation should result in increased breathing rate, along with the increased blood pressure and heart rate].

Does respiratory depression and physical weakness due to physical illness explain the mild hypothermia that accompanies sympathetic activation in physical illness? Is there a link?

Does the mild hypothermia accompanying the hypercapnia cause the peripheral vasoconstriction that Kraepelin described in his patients during the depressive insanity stage of their manic depressive insanity?

Wh knows?

This needs studying…..Kraepelin thought so too.

 When Paula and I took that  first aid class for work [more than 20 years ago], we were shown how to measure involuntary respiratory rate at rest when awake on each other. We were to lie down and relax and someone counted our respirations for one minute with a stopwatch.  Lying down to breath, it was easy to see who had significant active exhaling [which is not normal].   What was fascinating is that in a group of 30 healthy adults, the RANGE of respiratory rates were as low as 3 breaths [Paula] per minute to as high as 30.   The average, of course, was around 12.
No one was aware of their own respiratory rate.  It is involuntary at rest. Everyone in the class felt normal. But they weren’t all normal.  Paula has active exhaling at rest; she thought everyone did, she thought this was a normal way to breathe; this is the only way she has left……and somehow she is fine.
I think that this is my point.
I think that people with too slow or too high respiratory rates at rest when awake, for whatever reason, will be at greater risk to the cardiovascular and neurological effects of respiratory insufficiency [and CO2 retention] and will not know it.  And if they also lose their minds they will be unable to tell you; all they will sense is a kind of dyspnea, well known in polio epidemics, ….no visible shortness of breath, instead a sensation of anguish, inability to speak more than a few words and reversible mental dullness……..along with their respiratory defect [their natural difficulty moving air in and especially out of their bodies is made more difficult due to physical weakness].And without a routine procedure to unmask such respiratory injuries/defects, we will not only do harm to these patients, but we will miss opportunities to help them move air in and out in times of further illness and injury and blood loss.
There is no reason for this in the 21st century.
My question to you is this; why are arterial blood gas studies not done  [as carefully and safely as possible]  on ambulatory patients with long term  complications affecting the circulatory system and cognition and mood?     Paula’s pulse oximetry and HCO3 and other routine blood tests are normal in health. ABG’s are not routine in Canada, not even in emergency departments. They rely on pulse oximetry only. Same for lung doctors. Same for neurologists [even though they know that muskoskeltal and neural issues will affect the ventilatory system and are often hidden.  
Of course we do not know what Paula’s  “normal” PCO2’s are in health.  No one would imagine testing her PCO2 in illness, especially if she was ambulatory and not in the I.C.U.
We have ABG’s. Yet no one uses them in clinical research to advance our knowledge of insidious and silent respiratory insufficiency which patients themselves cannot signal because this is part of basic vital signs orchestrated by the brainstem and the circulation,  sometimes creatively due to whatever previous injuries the person may have sustained over their lives.[and who amongst us have ot sustained injuries over the course of our lives]. 
 We have been studying Paula  for 20+ years when we realized that doctors were freaked out when they heard about what we found; this despite their many tests …[but not ABG’s],  they gave her to make sure she was not dead or dying.   They showed absolutely no scientific curiosity about the biological phenotype she represented [there are others like her] or what autonomic nervous system injuries  she may have  sustained over her life.
We found out…from her family…that due to circumstances of poverty and poor nutrition, housing, ventilation, exposure to chemicals from cooking and heating fuels  [coke ovens were big in 1955 France to heat ones apartment],  her Mom and Dad had had Rickets and her Mom had crooked lower body bones.
So she got stuck in the birth canal during her birth, was born not breathing [anoxic], was suctioned [swallowed meconium], was resuscitated [hyperoxia] and then transfused [probably adult blood products]……She was perfect from then on….a medical miracle ….in 1955 Paris, France!  
 Her lungs are completely normal and healthy.   Her tidal volume is normal….5 L per breath….note it is not abnormally deep….it is simply normal….despite her too slow breathing rate. Her minute ventilation is 1.5 L. And no she does not take drugs or practice yoga.   She exchanges only 1.5 L of air in health…[which makes sense I guess if one wishes to be adapted to living in polluted air]… perfect health…right now, as I have [Zoom] coffee with her.   The assumption of 6-8 L is wrong, for people like Paula or for people who’s baseline [unmedicated] breathing rate [and with healthy lungs] is too fast.  Their neural and motor defenses are also more limited.

And no one can explain that either!   ***** Which makes it exceptionally significant to our scientific understanding of the complex motor act of breathing.
This probably explains her unique biology,  and that of others who successfully survived injuries at birth or in early childhood.
The brainstem and autonomic nervous system controls everything in the body and can adjust in ways we cannot even imagine,  all revealed easily, I think, by the vital signs,   Respiratory rate, Heart rate, blood pressure, and body temperature  during times of health and during times  of illness.   Some people will require extra help [modern supportive medical care] to recover because of past injuries/defects that nobody is aware of, including them.
This is to say that people can have respiratory defects or injuries and have no idea and will show no signs, except for a higher risk of carbon dioxide retention making full recovery from major illness or surgery more difficult for long periods of time.
Dr Emile Kraepelin found abnormal breathing rates in thousands of his patients during the different stages of unmedicated Manic Depressive Insanity in the 1900’s.   He understood that these poor souls had respiratory defects. Despite this, the bipolar patients were the only ones in the asylums not only to survive, but to have long periods of remission where their physical and mental health was restored- without- as he put it, permanent brain damage.
This is most likely because the effects of carbon dioxide retention are reversible [with supportive care or simply when the patient heals from a virus on their own.  Without supportive medical care, the attacks could disable patients for decades…wasting large periods of their lives.
This happened to Paula long ago.
We found out that she cannot raise her breathing rate , when exposed to high levels of indoor carbon dioxide or other pollutants, and she cannot raise her breathing rate when suffering from a virus  and this puts her at a big disadvantage, doesn’t it?   
We simply measured her respiratory rate like we were taught, during health and during that time she was ill,  and this is how we found out that her breathing rate is not only too slow [respiratory depression] ;  she cannot respond to chemical stressors.   And no one but us knows this. Because no one measures respiratory rate at rest when awake.
We even replicated this with a respiratory plethysmograph  [in the form of a modern Hexoskin Shirt].
Her breathing rate is fixed at 3 breaths per minute, and only rises in response to locomotor activity [and even then it is still sluggish and abnormal] and to physical  touch. [ interestingly, her breathing rate is much more responsive to physical touch -I guess those sensors are intact! ].
This suggests damage to nervous system sensors commanding muscle; most likely those in the neck and torso, I would think.
When she had that period of illness and cognitive impairment [from which she completely recovered..but it took a long time due to lack of any supportive medical care]…..she was unaware of breathing difficulties [and did not complain of any], had no visible shortness of breath, still had increased work of breathing- which no one noticed  [as she does in health], BUT she experienced huge Anguish, Fear and Distress and did not know why.  In early respiratory textbooks during the polio epidemic, this sensation was understood to be a form of DYSPNEA.   Today, this has been forgotten.
We think that she had retention of CO2 in the blood, which could have been measured by a arterial blood gas test, which is never given to delirious or demented ambulatory patients , even as a scientific exploratory tool to understand more about carbon dioxide in the blood and the many ways the brain and the circualtion have of dealing with it because carbon dioxide is a NORMAL product of cell metabolism.
I am disappointed in the lack of scientific curiosity in the medical population.
If Paula ever gets sick again [G-d forbid,], she would want acid base studies to be done in order to be able to restore her cardiovascular and neurological health and to restore her cognitive abilities.
She would be furious if left to slowly die from a potentially reversible dementia at home or in a psychiatric or neuropsychiatric facility or in a nursing home, without investigating further.
So what if ABGs are a little risky, so is surgery….I do not understand….and I have been urging doctors to become interested in this ever since we found out about Paula.
And by the way, we suspect that the sensors of those people with the too high breathing rates have also been damaged, impeding their ability to lower their respiratory rate in response to chemical stressors.
Please let me know if you have any questions.
We think that this information will help you to better understand post covid symptoms , both neuropsychiatric, neurological, and cardiovascular and will help further our knowledge  of our carbon based biology.
Please share this email.Minute Ventilation is not invasive and will be a great start.Please think about ABG’s as a scientific tool.
Please  look at our blog on Mind and Loss Of Mind…     where we write our ongoing thinking, as it progresses.
We have one brave pulmonologist/physiology professor teaching us respiratory physiology and he agrees that Paula’s existence provokes all of us to explore what we thought we understood but clearly don’t –  because Nature is more clever than we are, it seems- and more creative too.
I hope you use this to learn more about how to help post covid patients with lingering neurological syndromes. ….Their lives will depend on it…..Their lives will depend on you.
Best RegardsBrigitte

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