What do I mean by that? What have I learnt from Paula [and Jerry and Louise and Anna and others mentioned in this series of blogposts? They all had some abnormality to their vital physiologic signs. This was a major clue that was ignored. [no one thought of looking at their physiological function. Moving air in and out of the body is the first thing to check. The respiratory rate is an easy non invasive way to look at the function of the skeletal motor system. It says nothing about the lungs but says a lot about the state of the nervous system and the neck and trunk. If abnormal-too slow, too fast, irregular, etc…it is a major clue.
The proper function of the brain and of the mind depends first and foremost on the ability to move air in and out of our bodies. The verb ” to move” is the key concept here. We move air in and out with our bodies. We move air in and out of our bodies with nerve network messages directing the skeletal muscles. We move air in and out with the aid and direction of the brain. At birth, we need outside help to start breathing, a healthy slap on the back. If the body is hurt, damaged, injured in some way, we may have difficulty with this vital function, especially under duress [meaning physical duress]. Anything increasing the difficulty of moving air in and out regularly and effectively. When difficulty occurs, we may, as at the start of life, need supportive help once more, in order to keep moving air in and out of the body enough so that we can continue to function.
Paula lost her ability to function at the age of 43, at the peak of successful middle age life, family and career, as she was slowly becoming menopausal. Without careful attention to restoring her mental function, she would have ended up permanently demented. No one checked her vital signs. No one checked her motor ability to exchange air.
I do not use the word demented lightly. She woke up in the middle of the night one day, in a state of panicked fright which lasted over a year. During that time she forgot how to teach [a job she had been doing for the past 20 years, she forgot how to converse with people, and she forgot her own address and phone number and was unable to remember that she could not remember these and other things.
Unlike patients with Alzheimers, she did not repeat herself out loud, because she was short of breath AND breathing abnormally, very slowly and deeply, and was unaware of this. She spoke very little, and when she did speak, it was in short 2-3 word sentences. Her voice was weak and quiet, not her normal voice at all.
Paula’s doctor did not think to check her basic vital signs. He did not measure her resting respiratory rate. He had her come for psychotherapy. She could barely think. She could barely speak. She knew psychotherapy was a waste of time. She endured 10 years of “talking therapy”. Talking therapy does not work when one is demented.
Paula’s doctor threw different medications at the problem, We knew that he was unaware of the severity of her problem. So we evaluated each medication or combination of medications according to whether they improved Paula’s mental function and memory for her address. Memory for her own address was a shortcut to understanding if her autobiographical memory was improving with the help of any of the medications. The doctor did not do that. He did not even realize how impaired she was. He did not understand that he had to return her to her baseline mental status. The mood was a feature of her inability to move enough air in or enough air out. The lethargy and fatigue [which she was again unable to speak of] was due to her inability to breathe.
Paula was aware of the sensation of mild suffocation ….[it is never mild, even when mild],…. but did not recognize the sensation as such; she was only aware of the immense fear and distress that overcame her and dominated her person for over a year. She was too distressed [distress as a physical sensation not the emotion] to sleep very well. Imagine, as they say to understand cystic fibrosis, imagine what it is like to breath through a straw. She was experiencing a different but equally unpleasant distressing sensation. Paula was unable to explain what she was enduring.
No one knew. No one understood. Everyone misinterpreted her reactions.
She most likely lost the ability to protect her airway [a well known consequence of altered consciousness and mental status]. This is most likely why she instinctively did not eat or drink. She lost her awareness of her own bodily needs, she felt no hunger, thirst, need to urinate or defecate AND was unaware of this. All was blotted out by fear, constant, never-ending fear.
The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac.[ I would add non progressive permanent injury to disease states] Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles—again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine. Disorders of the Respiratory Muscles Franco Laghi , and Martin J. Tobin American Journal of Respiratory and Critical Care Medicine > List of Issues > Volume 168, Issue 1
In retrospect, it is astonishing that no one realized the importance of a fully functioning body to the ability of the mind to fully function. The fastest way to tell if someone is moving air in and out effectively is to carefully count their resting respiration rate…with a stop watch, preferably when they are lying down and trying to relax. It does not matter if they know you are measuring their breathing rate.Respiratory rate pattern is important. The pattern can be regular and abnormal, as is the case for Paula. Or it can be irregular, intermittently fast with apneas, like is the case for Jerry. It is useful to measure respiratory rate for a period of 5- to 10 minutes in order to understand the pattern. Because Paula’s ventilation was very stable, very regular, but abnormal, it attracted no attention unless you measured it carefully. Then it would not have been clear what to do. Treatments are possible, since Paula recovered, despite everything. Since , in Paula’s case her respiratory defect/injury cannot be corrected, treatment must restore her mental function. This is most likely the best one can do. And it is enough to make the difference between being able to function and not being able to function. Tracking mental function is the best we can do to evaluate the success of treatment. Getting pH of the brain or PaC02 of the brain tissues or measuring intracranial pressure is too invasive so the east we can do is evaluate treatment by testing mental function. This is all Paula and I did. And it worked. And we knew it would work because of Dr Emile Kraepelin’s care fully studies done over 100 years ago.We knew that manic depressive attacks would remit even without treatment, but very slowly, too slowly.
And respiratory rate can be measured without being in critical care. Abnormal respiratory rates are an important clue that explains the outpatient ‘s deterioration. And acute mental status changes reflect the deterioration in the patient’s physical state. These mental status changes can become chronic without treatment to support whatever physical function is failing.
Paula’s respiration rate during her attack of altered mental status and psychomotor retardation was 2.5 breaths per minute. Her normal respiratory rate when healthy with normal mental status is only 3-5 breaths per minute and that seems to make all the difference. In health, we now know that her brain is able to juggle tidal volume during rest or during exercise so as to maintain minute ventilation. Her respiratory rate in health, rises only sluggishly with exercise. All these tests [respiratory rate, tidal volume and minute ventilation] are able to be done at bedside in any patient, including ambulatory patients with sudden episodes of altered mental health and illness related undernutrition and dehydration and muscle weakness and muscle wasting. Paula had all of these signs, had any one looked for them systematically.
Paula’s respiration is very regular and constant with active exhaling which is very easy to see when she is lying down. She uses her abdominal muscles to squeeze every last bit of air she can out, most likely to increase her tidal volume as much as is possible for her to do at rest. This involves work on her part and it takes time. Paula’s respiratory rate is 3-5 breaths per minute. Her slow effortful breathing does, however avoid hyperinflation and air trapping. Her lungs are completely normal.
Some neuronal networks to the body seem intact or maybe even hyperactive.
Case in point; There is neural network involved in breathing rate and depth, sexual arousal [with physical stimulation] and the brain. As people become sexually aroused, their breath shortens and quickens. For some, their breath becomes so rapid that they hyperventilate. Some people even faint as a result. Paula does not faint but her respiration becomes super fast and shallow. So that particular network is intact, or maybe even hyper-responsive. Once the stimulation stops, the breathing returns to the person’s normal. It takes 5 minutes or so to return to the resting rate. So certain networks are intact and can speed up the rate of ventilation, while other networks seem to be broken.
This may explain how Kraepelin found too slow respiratory rates in the depressed phase of manic depressive insanity and irregular, often too fast respiratory rates in the manic phases. Stimulation of different networks will produce different patterns of motor ventilatory responses. More research is needed to see if Kraepelin’s results can be replicated in unmedicated patients today.
No one since Kraepelin has looked at abnormal respiration rates in attacks of bipolar illness.
And yet, abnormal respiratory rates point to a problem in the ventilatory network responsible for providing, in the correct ratio’s, the necessary oxygen to tissues while exhaling carbon dioxide produced by the cells after transforming the oxygen into energy .
Paula’s other vital signs, are completely normal when she is well, even with breathing at her usual 3-5 breaths per minute. During Paula’s attack of altered mental status, though her blood pressure rose, as did her heart rate, and her body temperature decreased [mild hypothermia] with accompanying systemic vasoconstriction [cold, pale extremities-hands, feet, lips.]. She may have had reduced cardiac output [palpitations, heart murmur, etc..]. Her intracranial pressure might have risen if she was retaining carbon dioxide and this might explain the rise in blood pressure [a response to counter intracranial pressure]. She did not cough. [coughing would have raised intracranial pressure more]. It is possible that increased pressure in the head [if indeed Paula was retaining C02 in the blood] results in squishing of certain motor areas, resulting in decreased amount and speed of movement, decreased thought, decreased speech and a sequence of other hormonal actions which we recognize as the behaviour of depression. A domino effect, if you will, to this type of metabolic disturbance. This is what Kraepelin hypothesized. A logical hypothesis given the pattern of abnormal vital signs he obtained in his studies on the different stages of attacks of manic depressive insanity.
Mania resembles the Cushing response [a further increase in intracranial pressure] , with irregular breathing, declining but still raised blood pressure and intermittent bradycardia.
Pressure, electrical stimulation and physical squeezing of brain tissues results in motor behaviour, as we learnt from Dr Penfield’s famous experiments. Maybe this explains psychomotor retardation and psychomotor excitement, who knows?
The real mystery is how Paula has done so well in her life until the age of 43, with such an abnormal pattern of breathing? Part of the answer is having enough good food to eat and a roof over her head and pretty healthy organs, including her lungs. She did survive a bad case of childhood measles, chicken pox, her share of the flu, and even the whooping cough. She was able to give birth to 2 healthy children. She was able to cross country ski and take dancing lessons. She was able to work for decades as a teacher.
That reflects the wonder of the human body. She was able to function physically and mentally despite not being able to raise her breathing rate during certain metabolic urgency’s. Somehow the system was able to conduct workarounds with the help of all the other organ systems including behaviour. This is most likely why she chose a mostly sedentary job as a career. This is most likely why she did not play in competitive sports. This why she liked reading and going to school [more reading]. These activities are less taxing on the ventilatory system.
This is why respiratory rate is an important part of motor function, but does not necessarily suggest disability of any kind……until it does, as it did when Paula got sick. This is why it is an important vital sign to be aware of, especially when mental functions begin to fail.
The motor ability to move air in and out of the body can decline at any time, compensatory mechanisms can fail with increased load, same as in any machine producing motor activity.
It is important to understand where the problem lies. If a car stops moving, investigating the cause makes a difference in how one will approach the problem; it is important to know if the engine is destroyed, or if the timing belt has snapped or if the ignition is broken or if the car is simply out of gas or the gas watered down or if the battery needs changing or if it merely needs a boost after you left the lights on all night. An investigation and a hypothesis is needed to decide on the best solution, once you understand the problem. It is the same with altered mental status, altered mood and altered locomotor activity, especially if it persists. . And to begin your investigation of the problem, you need to measure the vital signs, especially starting with the key motor system-measurement of resting respiratory rate.
It is obvious, once you think about it.
The motor act of breathing, psychomotor retardation [or quiet motor subtype of delirium], psychomotor excitement [or the active motor subtype of delirium], it is all related. Extensive neural networks activating any and all muscles can become damaged over time or under physical stress. Neck and torso sensors and muscles may fail in endless ways. This may or may not affect mental status.
We need to study this more.
Just as need to understand how to get the car started, and getting it to run at its best as quickly as we can, we must do the same with patients who suddenly stop functioning. These are remitting relapsing syndromes and we understand little about why this is.
We must not fail them. We must not give up.
We must do better.
This is what Paula and I have learnt.
to be continued………