Getting the word out to health professionals…………
Dear Dr X,
Thank you for your research and your thoughts. Regarding your article on ___________________ [this time it is …a paper about …the important contributions of remote monitoring to ongoing medical evaluation;... the one vital sign you have neglected is respiratory rate, which is especially important to evaluate, in all syndromes, but especially important in cases accompanied by acute depression with cognitive and memory loss.
Respiratory rate at rest is set involuntarily by the brain stem, and an intact neuromuscular ventilatory system is needed for the a reflex reactions to contain accumulating respiratory acids such as endogenous carbon dioxide, continually produced by normal cell metabolism. Breathing is a team effort involving the lungs, the brain and the skeletal muscle fibres and central and peripheral nerves and nerve fibres. And efficient enough breathing is very important to the function of the mind, which is what concerns me in this blog called : Of Sound Mind ; Mind and Loss of Mind, Conversations Between Paula and I.
I am not a scientist or a doctor but I have learnt from personal experience that baseline involuntary respiratory rate at rest is unconscious, whether it falls in the normal or abnormal range, whether it involves active exhaling or not, whether the dead space is increased or not. No one is aware of their own baseline resting respiratory rate or whether or not is is normal. And that is most counter intuitive. The baseline respiratory rate is not an indicator of lung function, necessarily, but it is an indicator of neuromuscular status and possible neuromuscular injury affecting the motor part of breathing . And the motor part of breathing must be intact in order for the body to respond effectively to fluctuating acid base balance affecting cells, tissues and the different organ systems, including the blood.
We forget that breathing is, at a minimum, a 2 part process, involving the peripheral skeletal respiratory muscles and nerves and ganglions etc, as well as the lungs. We forget that baseline respiratory rate can fail to keep up with the continual production of respiratory acids [endogenous C02] due to unseen and unsuspected and unfelt peripheral nerve and muscle fibre injury contracted after a major illness like COVID or indeed after any illness or injury. And when we feel the effects of this, we will not know what is wrong and will need others to know the protocol to follow. The protocol that Dr Emile Kraepelin began to use at towards the end of his career .
This kind of neuromuscular injury is not progressive and can produce a pattern of hypercapnic encephalopathy and fixed increase to intracranial pressure because of the fixed and/or impaired response to the increase of PCO2 affecting the brain tissues, surrounded by the skull, explaining the fixed patterns of behavioral and cognitive changes and nature of mood decline and cognitive decline.[hypercapnia=bad mood, dose related bad mood].
Measuring breathing rate is non invasive and easy and can be repeated endlessly by anyone and is a major clue that supportive multidisciplinary medical support [nutritive rehabilitation, respiratory rehabilitation, ventilatory support- [non invasive if possible], treatment of hidden blood loss or hidden infections, etc] is needed until the patient regains their baseline mood and mental status. Because despite neuromuscular weakness or injury, medical support can alleviate and palliate mental status and bad mood.
The range of baseline respiratory rates at rest in healthy working adults was found in the early parts of the last century to be very wide; from as low as 3 breaths per minute [most likely with active exhaling] to as high as 28 breaths per minute, and unconscious- the autonomic nervous system coordinating all the body systems to maintain normal enough acid base balance.
We have learnt this and more because of my friend Paula, who took a basic first aid class [ for work] and learnt that her respiratory rate was only 3 breaths per minute [with normal mood and activity rates and normal mental status]. She had no idea. No one did. Doctors have forgotten how creative and resourceful the body can be in regulating its body temperature and its chemistry of its cells, despite hidden neuromuscular and mechanical injury.
So Paula is not only still alive and happy and smart and active, twenty years later, she is still thriving, and is unaware of her respiratory rate and largely unaware of her active exhaling needed to approach a normal enough minute ventilation. When healthy, by the way, we found out that her blood pressure, heart rate [and heart signs] and body temperature are completely normal.When unwell [eg. recovering from a virus] , Paula’s blood pressure rises [a lot], as does her heart rate [palpitations, arrhythmia, murmur] and her body temperature drops [cold and pale and even blue hands and feet and lips]. Her baseline respiratory rate stays fixed at 3 breaths per minute. Her RR does not rise during respiratory challenges from physical illness. It would rise and should rise [as a means to better regulate rising respiratory acids, but it does not plus it is already very low, lower than it should be, even in health. You do the metaphorical math. This means that the physiological system is stressed and awareness of this hidden stress is clearly important for her to recover.
It seems obvious to me that Paula is at risk of ventilatory failure due to her fixed, low baseline respiratory rate [which by the way, rises only sluggishly with exercise] and that she is not aware of this and neither is anyone else, including doctors who never measure baseline vital signs and certainly never think to carefully count the stable baseline respiratory rate at rest. Doctors need to routinely measure baseline respiratory rate as a first step to evaluating neuromuscular strength in illness, possible nutritional deficits contributing to neuromuscular weakness, and possible damage to peripheral structures affecting the motor act and flexibility of the ventilatory system aside from and in addition to the lungs. Abnormal baseline breathing rate plus sympathetic activation during any illness [shown by measurement of heart and blood pressure] and abnormal thermoregulation accompanies by any level of altered mood, cognition, memory and locomotor activity will suggest hidden dose related ventilatory failure and will suggest need for more investigations including investigations of intracranial pressure, blood gases, capnography, especially during sleep or difficulties with sleep [insomnia] . Hopefully non-invasive methods will be developed for the harder to obtain measures, as time goes on.
Paula has most likely suffered permanent injury to her ventilatory system due to past injuries as a result of birth injury [she had a very difficult birth and required resuscitation] , or after upper respiratory infection or childhood illness [she had the measles and whooping cough for example], or perhaps after traumatic physical accidents in adulthood; eg physical trauma due to car accident or physical abuse or who knows what?
For example , we met one lady -let us call her Louise – who had a respiratory rate of 8 breaths per minute when healthy [she was not on any medications at the time and did not practice yoga and did not take any recreational drugs]. I started to count the baseline respiratory rates of random people I met as a hobby. It turned out to be a great way to develop friendships after we had a laugh about my new hobby.
It turned out that in her childhood, Lousie had suffered major physical injuries when hit by a bus at the age of 5. She had actually forgotten all about it and never mentioned it to anyone. She had spent months in the hospital , where they did a good job of repairing her. She had no visible signs, no limping, nothing. But this childhood physical trauma may explain her lower than average respiratory rate. She might have had damage to the peripheral nervous system affecting her ability to manage her neuromuscular ventilatory system. No one but us learnt of her birth or pediatric history. No one else evaluated the baseline respiratory rate at rest. In retrospect, we could have looked at the overall pattern of all the vital signs, to see if sympathetic activation had been triggered or not, at any point, signaling a physically stressed state and possible start of growing but hidden ventilatory failure..leading to other health problems as she aged.
Louise and I became friends. Ten years later she developed Parkinson’s.
Still no one, except us, had looked at her ventilatory system and its flexibility or lack thereof, for managing respiratory and other acids in cells and tissues. No one else asked about her birth or pediatric history or of injuries incurred in adulthood. It is as if people thought that this syndrome came out of the blue, unrelated to the state of her body, because possible injury or damage to the body was not visible and not evaluated, the vital signs being the most simple to look at since they are, as everybody knows, basic physiological signs necessary for basic functions of the body and of the brain and of every system in both. And disruption of the baseline at rest vital signs, in particular the respiratory rate [linked to invisible chemical balance of the blood and tissues] is a major CLUE to mechanical damage to the physiological systems.
Louise is under treatment for her advancing Parkinson’s disease. We measured her respiratory rate again.[for fun]. Louise was now on medication to control the shaking. Interestingly, with Parkinson medication, her baseline respiratory rate at rest was now a steady 20 breaths per minute . [where in health and without any medication, her RR had been 8 breaths per minute]. Perhaps this is why the medication worked, [it worked for a while], who knows? Perhaps the medication helped with her acid base balance, perhap it helped her to better maintain the pH of her brain tissue or of the blood for a time. No one knows. No one is looking at the role of the stable normal or abnormal baseline vital signs in different syndromes, neuromuscular or other. And yet these vital signs of respiratory rate [and depth and pattern] , heart rate [and heart signs] and blood pressure and body temperature will affect every chemical and physical reaction going on in the various cells of the body. Why not evaluate the patterns of these vital clues ? There is no good reason except, perhaps, lack of imagination and common sense.
Here is another syndrome I came across; Heart failure. Is there a pattern of abnormal basic vital signs in heart failure with quiet mental impairment? Is neuromuscular dysfunction affecting the motor part of breathing affected, at different stages of this chronic illness? Let us look at the journey of Paul, a friend with heart failure.
Paul had had a pattern of breathing that I learnt was called Cheynes Stokes ventilation [which no one noticed] and that he had a pattern of lowered blood pressure and poor circulation and kidney impairment and [hidden blood loss- which no one linked to his lowered blood pressure] and altered mental status in the form of memory and cognitive impairment [again, which no one noticed] and this pattern of vital signs should have informed his treatment...
Paul especially needed chronic support, [I think], and needed help moving air in and out of his body, as well as help removing secretions and other respiratory rehabilitation methods available now that we are in the 21st century …I think that this would have helped him to regain his baseline mental status and to restore his mood, despite his heart failure.
Paul had immense dyspnea which was not visible due to neuromuscular damage or weakness affecting the neck and torso. He was not aware that his discomfort was due to dyspnea, it is not always a recognizable sensation, because it involves an internal source of dose related chemical suffocation. Even with clear lungs, the clue is in the motor respiratory rate and other investigations [minute ventilation, ABG tests, capnography with sleep tests, nutritional deficiency or blood loss weakening the heart further, etc…]. All easy to do routinely when the patient becomes weak, malnourished due to lack of appetite, and confused. Paul was all of that, yet no one really noticed because his decline was so gradual and he was still pretty strong despite his decline, compared to most. [Paula had been athletic in his youth].
Physiology and the pattern of pathophysiology, as shown by thinking about Paul’s abnormal vital signs [especially the respiratory rate and the effect of physical weakness on ventilation and thus chemical balance of the body and brain] would have been key to helping him have a better quality of life during the last tortured ten years of his life as he slowly declined and no one understood and mistakes were made and made again. Vital signs could have provided the basic roadmap explaining all the rest and providing ideas to reduce the suffering he endured. [he was never even sent to a heart failure clinic because the doctors did not realize he had heart failure…..I think a quick review of his vital signs would have helped them to realize just how sick he was for years; in spite of being physically stronger than most people as sick as he was. Appearances are deceptive but baseline vital signs can tell the inside story.
Vital signs can also provide a roadmap for the countless details we learn from molecular and biochemical research.
Vital signs can help organize the thousands of facts we are learning , without missing the overall patterns that drive these details under different conditions.
Biology counts! Physiology matters! Mechanical function counts! Injuries affecting function counts! We have a lot of tools to help maintain acid base balance during mechanical failure of the mechanical neuromuscular ventilatory system and this is key to alleviating silent and unnecessary suffering during stages of chronic debilitating illness, eventually affecting mental status unnecessarily.
Paul’s heart could not be saved, but his breathing could have been supported and his anxiety and bad mood [from hidden suffocation] alleviated and his mental status retained. By learning some basic physiology and pathophysiology, by learning and thinking and evaluating the basic vital signs which keep all of us alive and thinking.
I ask you [and all health professionals] this question….do you know what is the basic pattern of vital signs in depression with so-called pseudo-dementia [ or psychomotor retardation or chronic depressive/manic attacks in this specific pattern of quiet delirium ] ? Of course you don’t. You have not given this a second thought.
Dr Emile Kraepelin thought about this when he measured the pattern of vital signs in many of these [unmedicated] patients toward the end of his career  . Dr Kraepelin found abnormal patterns of baseline respiratory rates and appropriate responses from the other vital signs he looked at [BP, HR, Body Temperature] in the stages of depressive and manic insanity.
He concluded that manic depressive attacks were attacks of metabolic dysfunction due to ventilatory defects providing impaired responses to respiratory acid base balance after some physical trauma. injury or illness.
Have we studied this possibility today, in the 21st century?
Of course not. No one remembers this part of Kraepelin’s research. No one wants to even think about the possibility of depressed ventilation in unmedicated bipolar depression or of Cheynes Stokes patterns of ventilation in the same patients in mania. Even if such discoveries bring about improvements to abnormal mood and mental status, we are too scared to even look into this possibility.
We need to study this and see if we can replicate Kraepelin’s findings today in unmedicated seriously ill bipolar patients. [studying medicated patients will distort the findings because medications can alter breathing patterns and other vital signs.
Here is another question to ponder over. What is the basic pattern of vital signs in early dementia? I would bet that neuromuscular damage affecting the flexibility of the respiratory rate, depth and pattern and reflex responses to acid base disturbances will help us learn the links between ventilation, the ability to move air physically in and out normally, in order to maintain chemical homeostasis and the ability to retain baseline higher order memory and thinking.
Why not look into this?
Why the resistance, the fear ?
If the ventilatory system is indeed permanently broken, we already have and can improve solutions to support this mechanical motor behavior, often retaining the normal function of MIND.
Isn’ this possibility worthwhile?
Hypercapnic encephalopathy is largely reversible, with supportive care. Unless one drops dead. [carbon dioxide, endogenous or not , is ultimately a euphoriant, a deliriant and an asphyxiant [dose related]].
Hypercapnic encephalopathy can result from many physical illnesses, injuries,undernutrition as well as added exposure from poor living conditions.
The lungs are very important. But so is the unprotected mechanical neuromuscular system that pushes air in and out in the appropriate ratios.
Please help me to advocate for the use of the vital signs, especially respiratory rate [and minute ventilation if abnormal and if recognizable patterns of mental and mood and behavior changes occur] in learning more about the hidden internal chemical and mechanical stressors that can cause chronic and possible reversible failure of one’s mind and mood. Let us know what you think.