If respiratory rate is known to be abnormal at rest at baseline; regularly too slow at rest or regularly too fast at rest or regularly abnormal at rest, it is a BIG deal and it is an important metabolic and physiologic CLUE that must be investigated because of its effects on pH of the blood .

From : https://www.ncbi.nlm.nih.gov/books/NBK537306/.

Physiology, Respiratory Rate

Charilaos Chourpiliadis; Abhishek Bhardwaj. in

StatPearls [Internet].

Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Last Update: September 12, 2022.

and I quote;

“Introduction

Respiration is a vital process for the normal function at every level of organization from a cell to an organism; oxygen, supplied by local circulation at the tissue level, functions at the mitochondrial internal membrane as an essential mediator for the energy release. In mitochondria, digested nutrients undergo metabolic reactions, end up at the level of the electron transport chain, and release high-energy compounds (ATP). The main byproduct of this process, carbon dioxide, gets released in the venous blood returning to the lungs. Carbon dioxide diffuses through alveolar walls and dissolves in the exhaled amount of air. The respiratory rate, i.e., the number of breaths per minute, is highly regulated to enable cells to produce the optimum amount of energy at any given occasion. A complex nervous system of nerve tissues regulates the rate of oxygen inflow and carbon dioxide outflow. It adjusts it accordingly in conditions that tend to derange partial gas pressures in blood. Respiration is a process involving the brain, brainstem, respiratory muscles, lungs, airways, and blood vessels. All these structures have involvement structurally, functionally, and regulatory to respiration.” https://www.ncbi.nlm.nih.gov/books/NBK537306/. StatPearls. Physiology, Respiratory Rate.

There you have it..

If respiratory rate known to be abnormal at rest at baseline; regularly too slow at rest or regularly too fast at rest or regularly abnormal at rest, it is a BIG deal and it is an important metabolic and physiologic CLUE which needs to be investigated, especially when brain function and function of the mind begins to derail in stereotyped ways-ie. entrenched delirium [all motor subtypes], manic depressive insanity, and any neurological or psychiatric derangement which accompanies chronically abnormal respiratory rates.

Books will talk of the importance of vital signs;

“Along with blood pressure, temperature, and pulse rate, respiratory rate is one of the vital signs routinely monitored in a clinical setting.” https://www.ncbi.nlm.nih.gov/books/NBK537306/. StatPearls. Physiology, Respiratory Rate.

Yet respiratory rates, in clinical practice, are only given lip service .;

At most, doctors and/or nurses glance to see if they can see any respiratory distress or not. If not, more than likely they will report an average respiratory rate which they know is 15 breaths per minute at rest, give or take 5 breaths.

Assessment of vital signs is essential for detecting acute changes in a patient’s condition. Vital sign assessment allows for the identification of signs of improvement or if the patient is deteriorating, alternate or emergency care to be initiated. Assessment of these clinical parameters plays a fundamental role in early detection of patient deterioration but only if nurses/doctors understand the basis of the signs, and they are measured, communicated and acted upon [1].

Despite the importance of vital signs monitoring, research indicates these signs are not consistently assessed, recorded or acted upon in the acute setting. Numerous studies have highlighted a lack of vital signs measurement in the hours immediately prior to life- threatening adverse events or admission to Intensive Care [2-4]. In a randomized trial of medical emergency teams in 23 Australian hospitals, more than 75% of patients experiencing an adverse event had at least one vital sign unrecorded immediately before the event [5]. Other studies have also shown that when vital signs are abnormal, clinicians’ responses are often inadequate [6,7].

Respiratory rate (RR) as a key vital sign has numerous clinical uses. These include to obtain a baseline for comparison or post- operative monitoring, to identify blood transfusion or drug reactions, and to detect compensation to acid-base abnormalities [8,9]. A change in respiratory rate is also an early indicator of deterioration. …. [ and by the way, going crazy is a definite and serious indicator of physical deterioration] ]…….Early identification of this change allows prompt intervention and thus reduces the risk of organ failure and death [10]. Tachypnoea for example is one of the most significant predictors of in-hospital cardiac arrest and admission to intensive care [11]. The ability to identify a deteriorating patient is also essential for avoiding poor clinical outcomes and to ensure the effective intervention of rapid response teams [12].….

Acute onset of or entrenched of serious and incapacitating mental illness [eg. psychosis] is a physical sign of a patient who is deteriorated compared to their baseline, previous to having become ill. And yet often only a cursory medical investigation is done despite the fact that we know the “altered mental status” [with altered mood and altered motor activity] has about a zillion causes and is like looking for a needle in a haystack. Serious mental illness is the very definition of “altered mental status” with an organic cause that is not obvious and that no one is investigating, medically.

Neurological and psychiatric patients are not going anywhere soon, so why haven’t we developed the ability to organize our search for that “needle” , starting with key clues like baseline respiratory rate, blood pressure, heart signs and heart rate and body temperature? The pattern of these physical signs will tell us a lot about how the autonomic nervous system is attempting to keep pH in check , in order to keep us alive, if not always sane. Why is this not done while the patients are in hospital or when treated as outpatients?

There is no difference between “altered mental status [all psychomotor types] and psychosis- none. We simply have not looked for the metabolic problems that underlie psychosis or manic depressive insanity or schizophrenia or anorexia nervosa , etc……

That, in my opinion is the real stigma harming these patients.

That, in my opinion, is discrimination against these patients.

That, in my opinion, is partly due to fear of these patients.

People who are losing their minds are scary, whether they are in a state of psychomotor retardation or psychomotor excitement or in a mixed state. And doctors are afraid of them. And doctors can sense their proximity to death. Because these patients, even when chronically ill for decades, are close to death during their lives. They are chronically critically ill. This is why they have shorter lifespans than people without this kind of chronic critical illness.

Despite its clinical importance, respiratory rate has consistently been the least frequently measured vital sign [13-15]. An audit of 211 adult post-operative patients in five Australian hospitals for example found only 17% of medical records had complete documentation of vital signs, with respiratory rate the most neglected [16]. Similarly in a retrospective review of 1000 patients who died in 10 British hospitals, poor clinical monitoring was responsible for a third of preventable deaths [17]. This neglect of vital signs is not a new clinical problem and is yet to be adequately studied [18]………In a similar prospective, observational study in six tertiary referral hospitals in the United States, respiratory rates of 18 or 20 breaths/minute accounted for 72% of all recordings, and documented respiratory rates were higher than directly observed measurements [45]. Other research has similar findings. In a study conducted in an 80 bed rural Australian hospital, 484 respiratory rate recordings were reviewed [46]. In 83% of cases, the recorded respiratory rate was 16 or 18 breaths per minute; some observation charts indicated the respiratory rate was always 18 [46]. The findings of all these studies suggest that respiratory rate measurements might be guessed or made up much of the time.

Regular baseline respiration rates are [and I am still quoting StatPearls Physiology Respiratory Rate here ]… ” highly regulated…. by a…..a complex nervous system of nerve tissues that regulate the rate of oxygen inflow and carbon dioxide outflow. ……to enable cells to produce the optimum amount of energy at any given occasion“. …….and is is not necessarily a visible process UNLESS the respiratory rate is carefully measured at rest in order to establish a baseline.

Careful manual measurement of respiratory rate at rest is easy to do ACCURATELY by asking the person to lie down and after a few minutes, carefully and mindfully, counting the respirations with a stop watch. It is easier to see if abdominal muscles are used for exhaling [this is abnormal- exhaling is usually a passive process not an active one.]

Nowadays, one can utilize electronic devices [eg. the Hexoskin Smart Shirt- used by NASA -which has a respiratory plethysmograph embedded in the shirt and comes in different sizes or one can use whatever else is available in the market and is proven to be accurate accross a wide range.

It is important to note that the range of respiratory rates are wide, from as low as a baseline of 3 breaths per minute [even 2.5 ] at rest to as high as baseline 28+ breaths per minute at rest. This range represents normal respiratory rates for healthy active adults.

How do I know the range of respiratory rate in normal healthy adults?

Well, if you have been reading this blog, you know that I learnt this when my friend and colleague Paula and I took a mandatory first aid course for our work as college teachers. At that time [a long time ago] they taught us how to count respiratory rates using the way I described just now. In the class of 30 or so college teachers, the range of RR was as low as 3 breaths per minute [this belonged to my friend Paula- much to her and everyone else’s surprise] and was as high as 28 breaths per minute at rest. Apparently this wide range was known to early physiologists [and forgotten]. Some who work in hospitals that use electronic devices for measuring RR , also know of this wide range in healthy and not so healthy people.

Paula’s case was especially interesting to us because 1] she had no idea , meaning this was going on “under the radar” and 2] we had no idea – meaning- no one can tell. and 3] even knowing that this is her RR, one still cannot tell and even she cannot tell [except intellectually]. and 4] why on earth would the nervous system arrange for anyone on this planet to breathe at this ridiculous and [maybe dangerous] rate, using the abdominal muscles as a pumping mechanism to aid in breathing ? It seemed to be a tiring way to breathe. And yet Paula did not seem tired, she seemed normal and energetic even. The people with the RR at the other extreme were also normal and energetic, they were similar behaviourally and this seemed strange as well. Paula, when asked, will say that she does not lack energy [when well] BUT she does experience breathing as work, rather than experiencing it simply as natural. Breathing is harder for her and she is aware of that. But the rate of her breathing? She has no idea.

What is even more interesting is that a clinician – scientist, who practiced over a century ago, also found evidence of what I call “broken breathing” in his unmedicated manic depressive patients. e immediately made the connexion between their state of insanity [different stages of] and possible problems with regulation of pH and metabolism of the cells. He found different levels and patterns of abnormal breathing rates in these patients during the locomotor different stages of their illness; depressed RR, Cheyennes Stokes or Biotic respirations, along with sympathetic activation [more so in slow locomotor states and less so in manic ones, he was surprised to learn, as well as visible circulatory patterns [vasoconstriction and cool, pale, even blue hands , feet and lips and low body temperature in slow locomotor states; vasodilation, red, flushed cheeks and higher body temperatures [with intermittent bradycardia] in manic phases.

This is really cool! What is going on in physiologically and metabolically this syndrome.? Suddenly the concept of mood disorder no longer cuts it. Syndromes of excitement in mania and fear/dread in depression make more sense as chemical reactions to fluctuations in PaC02 of the blood. Hypercapnia is known to bring about extreme sensations of fear and distress, and maybe even euphoria [although that might be due to accompanying hypoxia]..

Hypercapnea

Deepa Rawat; Pranav Modi; Sandeep Sharma. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK500012/

The exact history and physical findings are highly variable depending on the source of hypercapnia. Patients may present with a complaint of flushed skin, lethargy, inability to focus, mild headaches, disorientation, dizziness, shortness of breath, dyspnea on exertion, nausea, vomiting, and/or fatigue. More severe complaints include confusion, paranoia, depression, abnormal muscle twitches, palpitations, hyperventilation or hypoventilation, seizures, anxiety, and/or syncope.  Often, if a patient has a known history of asthma or chronic obstructive pulmonary disease (COPD), they will know the symptoms of exacerbation and present with this as the primary complaint.

An arterial or venous blood gas is possibly the most valuable laboratory test as it allows for evaluation of pH status, serum CO2, and serum HCO3. Additionally, an anion gap can be calculated to assist in determining if acidosis is metabolic or respiratory in nature. 

Treatment of hypercapnia should target the underlying pathology. HYPERCAPNIA. Deepa Rawat; Pranav Modi; Sandeep Sharma. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK500012/

To Be Continued and edited….still working on this….