In older posts I talk about doctors in Britain in the 1980’s who obtained measurements of minute ventilation [respiratory rate times tidal volume] in order to catch neurological impairment affecting breathing and gases in the blood. I recently found out that today, doctors not only never look at respiratory rate but they also no longer get a measurement of tidal volume. The reason for this is that neither will tell you about the condition of the lung and it is typically lung doctors who order lung function tests. Paula does not have lung problem; her lungs are healthy. Her lungs are not the problem. Yet she has a problem breathing. Her problem raised in her motor ventilatory system. The motor ventilatory system involves not only the respiratory controllers of the brain, but involves moving the muscles needed to move air in and out of the body- the respiratory pump that is just as vital to breathing as are the lungs. Yet the function of the respiratory pump is never tested anymore. Even when doctors have no idea what is wrong with their suddenly unwell and poorly functioning patient. Neurologists, emergency doctors, family doctors, cardiologists ,psychiatrists, etc..no longer order these tests to screen for possible injury to the motor ventilatory system that is responsible for moving air in and out of the lungs. They act like they do not know this system exists. To the detriment of the patient who knows something is physically wrong and causing huge distress, but have no idea what. This is when the patient is entirely dependant on someone other than themselves to figure out what the problem is. This is when someone needs to carefully check the patient’s vital signs, especially the to screen for an abnormal resting respiratory rate, which is key to understanding metabolic respiratory dysfunction, a common cause of sudden change in personality, mood and mental status. Yet no one bothers testing RR, BP, HR, and Body Temperature together to see if there is a problem.
What are health professionals for , if not to check basic vital signs in times of illness and altered mood, mental status and locomotor activity? In the young as well as the old. [and doctors do not even check the basic pattern of vital signs in the old, so what is left to say?
But there are lung function tests that measure resting respiratory rate, tidal volume and minute ventilation. These tests are non invasive and they can tell you if there has been some injury to the ventilatory system. The neural, mechanical, motor ventilatory system of the body. They can tell you when the more invasive arterial blood gas tests may be necessary in ambulatory patients who are doing poorly.
The test for measurement of respiratory rate, tidal volume and minute ventilation can confirm how abnormal and how constant an abnormally high or low respiratory rate is, and this test could be ordered whenever a person suffers from sudden strange, out of character [excitement or depression or abnormal distress] and becomes suddenly and chronically cognitively disabled. Sudden personality and cognitive and mood changes can signal a deterioration in the ability of the ventilatory system of the body to be able to meet a metabolic challenge induced by infection or exposure or to deterioration of physical health for any reason. If a person has a compromised or broken ventilatory system, they are at risk of ventilatory pump failure or compromised acid base responses and that, is a condition we need to learn more about.
Paula got tested specifically for minute ventilation recently; this means the machine measured her respiratory rate for 5 minutes [while reading a book] and measured her tidal volume.
Paula’s tests measure a respiratory rate of between 3-5 breaths per minute. [which is most unusual].
Her Tidal Volume is between 750 – 850 ml at rest. [which is larger than most people’s at rest, most likely due to her extra work of breathing. [her active exhaling-which is unusual].
Her Minute Ventilation is Normal.
And her oxygenation is normal.
And this shows that her respiratory controllers [the brain stem] are making sure her gas exchange is correct, by increasing her tidal volume at rest accordingly. But for some reason her breathing rate remains extremely low, requiring additional muscular effort to accomplish this and this is not a normal or easy way to move air in and out of the body.
Her minute ventilation is also maintained normally , as is her oxygenation, during exercise.
So Paula’s brain is managing her blood gases very well at rest and during exercise, despite her still low and unusual ventilation at rest and during exercise. We do not know why this is, only that it is this way. We do not know how her effortful breathing fares during infection, deterioration of body condition and/ or exposure to higher levels of CO2 in different environments. And we do not know how failure of this already broken system of breathing will affect how her health deteriorates, as it is likely to be different than most. Most people breath faster when ill or when exposed to higher levels of CO2. We do not know if this is true of Paula and we need to test this experimentally to see how she deals with these metabolic challenges.
This explains why Paula is well during health, despite having “different” ventilation and unusual breathing rate and technique. When Paula got physically ill though, she reports that her breathing rate stayed at 3 breaths per minute and that her normally normal other vital signs became abnormal as well. She became quiet, lethargic and lost her memory for personal information, such as her own address and knowledge regarding how o do her own job of 20 years. She became intellectually dull, not being able to read at her grade level [university] and lost her social skills. She was too out of breath to speak much and [weirdly]did not recognize that she was out of breath. She felt huge distress and agin did not know that her breathing was slow and effortful. It seems that no one is aware of their own resting breathing rate. In health, though Paula knew her breathing was took effort. In illness, she lost that awareness. She also was not aware of basic sensations like hunger, thirst, etc…She was silently but chronically mentally confused and in poor physical condition as her illness progressed. And this was mistaken for depression because her vital signs were not measured. And her vital signs were grossly abnormal.
As mentioned before, Paula’s breathing technique takes work on the part of her abdominal muscles, during exhalation at rest and this is not usually the case in normal people. And Paula feels it as extra work. It takes her a fair amount of effort to breath. if you bring her attention to it; she will report awareness of this effort. She assumed that everyone breaths like her so she thinks nothing of it. She is unaware that her breathing strategy is different from most, in health but also in illness.
Paula and I and Kraepelin suspected people like Paula have a higher risk of ventilatory pump failure during physical stressors such as vitamin deficiency, blood loss, infection, exposure [to higher levels of indoor or outdoor asphyxiants], poor physical condition [due to poverty or illness], further injury or wear and tear of aging, etc….due to the existing limitations in her breathing evident in health.
A sudden change in personality and failure to function normally at one’s baseline, along with distress which could be unrecognized respiratory distress could signal a hidden deterioration in breathing, independent of lung function. A sudden change in personality and failure to function normally at one’s baseline, along with distress which could be unrecognized respiratory distress could unmask a ventilatory defect [just like Dr Kraepelin hypothesized] and the failure to compensate, requiring supportive medical treatments. This happened to Paula.
A sudden change in personality and failure to function normally at one’s baseline, along with distress which could be unrecognized respiratory distress, could also unmask other unknown and invisible and hidden injuries, injuries or conditions affecting the blood, which need looking after.
This is why a sudden change in personality and failure to function normally at one’s baseline, along with distress which could be unrecognized respiratory distress, is a Medical Emergency requiring investigations; in order to try to save a person’s mind, avoiding possible death or physical deterioration or long term disability.
Current neurological and neuropsychiatric practice does nothing to try to avoid death, further deterioration [eg diabetes, cardiac problems, etc..] or long term, possibly lifelong disability.
All because of a antiquated tradition of looking at certain patterns of altered mental status [and mood] as psychological and under the patient’s control, rather than as a physical injury resulting in deterioration of health and longterm disability needing to be investigated and treated.
All because of a “road not taken”, the road of injury, physical mental disability, and investigation using tools such as machines that track minute ventilation to detect problems and to identify treatments to restore baseline mental status.
Paula lost her mind….and felt bad physically, and became hugely disabled.
Paula has a permanent hidden [in plain sight with measurement of minute ventilation] injury.
Paula’s mind was restored with treatment that was monitored to track return of memory and higher cognitive function.
Paula’s breathing is still broken.
Her condition should be monitored now that we know about it.
Except that Dr Kraepelin and Paula and I [and our respiratory consultant] are the only ones to know about it.
We need you to tell others.
We need you to talk about the importance of minute ventilation [respiratory rate and tidal volume] and the rest of the vital signs, whenever someone falls “mentally ” ill or becomes “delirious” or “demented”.
Altered mental status needs careful physical investigation in order to unmask possible injuries which could be preventing recovery of normal baseline mental status.
Please tell others to read this particular blogpost.
And stay tuned as Paula tries to get tested further to see under what conditions the ventilatory system fails…..
Stay tuned, testing continues in a few weeks.
Please let us know if you have questions.
Please let researchers [family doctors, neurologists, emergency room doctors, etc…] know about this blog; we would like their input.