Abnormal Respirations (2024)

Continuing Education Activity

Respiration, a physiological process, involves the exchange of gases between the body and the external environment. A meticulously balanced system within the body ensures the orderly process of respiration, delivering sufficient oxygen to tissues for energy production and efficiently removing carbon dioxide. Despite its seamless nature, respiration is vulnerable to abnormalities challenging its efficiency. Respiratory disorders can significantly impact a patient's life by impairing gas exchange, leading to reduced oxygen supply and a buildup of carbon dioxide. This can result in symptoms like dyspnea, fatigue, and decreased exercise tolerance. This activity reviews various respiratory disorders, underlying mechanisms, and clinical manifestations. The vital role of an interprofessional healthcare team in evaluating and treating patients affected by these conditions is emphasized.

Objectives:

Identify various abnormal breathing patterns, discerning subtle differences and connecting each pattern to potential underlying causes.
Apply evidence-based interventions effectively, tailoring treatments to specific abnormal breathing patterns and optimizing patient care outcomes.
Differentiatebetween abnormal respiratory patterns, identifying unique features to diagnose specific disorders and enable targeted treatments accurately.
Collaborate with healthcare professionals, including respiratory therapists, nurses, and specialists, to ensure comprehensive and multidisciplinary care for patients with abnormal respirations.

Access free multiple choice questions on this topic.

Introduction

Respiration is a physiological processinvolvinggaseous exchange between the body and the external environment. A carefully balanced system exists, encompassing various body organs that work harmoniously to facilitate respiration. This intricate network ensuresthe delivery ofan adequate amount of oxygen to body tissuesfor energy production and the efficient removal of carbon dioxide. Within the central nervous system, specialized respiratory centers integrate neural and chemical input fromdiverse receptors. These centers then signal the respiratory muscles, ensuring the upper airways remain patent anddrivingthoracic movements toregulate ventilationlevel.[1]Additionally, this process plays a crucial rolein maintaining the body's acid-base balance.

Although respiration occurseffortlessly and seamlessly, it is susceptible to various abnormalities challenging its efficiency. Thisactivity will explore different respiratory disorders,delving into their pathophysiology and clinical manifestations.

Function

Respiratory disorders cansignificantly impact a patient's quality of life.Many respiratory diseases disrupt the normal gas exchange process, reducing oxygen supply to the tissues andcausing an accumulation ofcarbon dioxide. Consequently, individuals experience symptoms like dyspnea, fatigue, anddecreased exercise tolerance.[2]To cope, the body activatescompensatory mechanisms, often involving an increase in breathing rate oreffort to maintain sufficient oxygen levels.

Inflammation of the airways isa protectiveresponse against environmental triggers. However, incertain respiratory disorders, such as asthma and chronic obstructive pulmonary disease (COPD), this inflammation canpersist chronically, leading toairway damage.A similar occurrence is observed in cases ofchronic coughassociated with bronchitis.

Individuals affected by respiratory disorders frequently experience fatigue due to the heightened effort required for breathing and the decreased availability of oxygen.[3]When combined with dyspnea, these symptoms can significantly limit a patient's daily activities, exercise capacity, and overall quality of life. Living with a respiratory disorder can also havepsychological consequences,leading to anxiety and depression. Patients often struggle with the fear of breathlessness,persistent symptoms, anddiminishedquality of life. Therefore, implementing appropriate treatment and lifestyle modifications is crucial to enhance the quality of life and prognosisforindividualswith respiratorydisorders.

Issues of Concern

Disordered respiration can be an uncomfortable and distressing experience for patients. Although specific data regardingits prevalenceamong ambulatory patients is lacking, the widespreadoccurrence of cardiac and pulmonary diseasesindicatesthe extensive nature of the condition. Cardiacconditions are among the leading causes of death in the US, often manifesting with dyspnea as a primary symptom.[4]Additionally, obstructive lung diseases, such as asthma and COPD, affectapproximately34 million people in the US, many of whom seekmedical assistanceto alleviate shortness of breath.However, the actual prevalence is likely underestimated due to the underdiagnosis of COPD.[5]Similarly, asthmapresents a significant global challenge, affectingapproximately 15% to 20% ofindividuals in developed countries and about 2% to 4% in less developed countries.

Tachypneais characterized byrapid breathing, with the average breathing rate for adults ranging from 12 to 20 breaths per minute. In newborns, tachypnea signifies a respiratory system issue that can become apparent shortly after birth. Itoften arisesdue to impaired fetal lung fluid clearance,resultingin respiratory distress. Transient tachypnea of the newborn is more prevalent in preterm infants, affecting approximately 1 in 100 preterm infants. In full-term infants,transient tachypneais observed in around 4 to 6 per 1000 infants.[6]

Hypoventilation refers to breathing at a slower and shallowerpace than normal, leading to impaired ventilation. Thiscondition ultimately results inhypoxemia and hypercapnia. One example of a disorder associated with hypoventilation is obesity hypoventilation syndrome,characterized bythe presence of obesity (body mass index [BMI] ≥30 kg/m²) and daytime hypercapnia (PaCO2 ≥45 mmHg)without any otheridentifiable cause for hypoventilation. Current estimatesindicate that 8% of the adult US populationis affected by morbid obesity.[7]Within this group, theprevalence of obesity hypoventilation syndrome is estimated to be between 20%and 30%.[8]Theoverall prevalenceofobesity hypoventilation syndrome ranges from 10% to 20%.[8]

Hypoventilationcan also be caused by various neuromuscular disorders, including amyotrophic lateral sclerosis (ALS), diaphragm paralysis, muscular dystrophies such as duch*enne and Becker dystrophies, Guillain-Barré syndrome, and myasthenia gravis.[9]The morbidity and mortality associated with hypoventilation syndromesdiffer based on their underlying causes. For instance, patients with obesity hypoventilation syndrome are more likely to be admitted to the intensive care unit (ICU) than individuals with similar BMI without hypoventilation.[10]

Clinical Significance

Eupnea refers to normal, unlabored, and regular breathing at rest. Disorders of respiration can stem from abnormalities in any component of the respiratory system, including the airways, alveoli, central nervous system, peripheral nervous system, chest wall, and respiratory muscles. Breathing is influenced by various factors, including blood pH (acidosis or alkalosis), carbon dioxide levels (hypercapnia or hypocapnia), and oxygen levels (hypoxia). The medulla oblongata and pons in the brainstem play a critical role in adjusting the rate and depth of breathing in response to these factors.

Clinicallysignificant abnormal respiration patternsencompass the following:

Dyspnea is thefeeling of difficult or labored breathing, often characterized by a sensation of air hungeror insufficient airflow. Paroxysmal nocturnal dyspnea (PND) is theabrupt onset of severe shortness of breath that occurs during the night, typically waking the patient from sleep.

Orthopneaisa specific symptom or condition in which patientsstruggle to breathe whenlying flat. Patients with orthopnea typically find relief by sitting upright or adopting a more elevated position, like being propped up with pillows. This condition is oftenlinked with heart failure.

Cheyne-Stokes respiration (CSR)refers toa cyclical breathing pattern characterized byapnea, followed by a gradualrisein respiratory frequency and tidal volume, and thena subsequentdecline in bothuntil the next apneic period occurs.[11]This pattern is commonlyobserved in patients with heart failure.[12]

Bradypnearefers toan abnormally slow respiratory rate, notably slower than the average expected breathing rate for an individual at rest. Thetypical adult respiratory rate at rest rangesbetween 12 and 20 breaths per minute. Bradypnea is commonly defined as a respiratory rate below 12 breaths per minute in adults, although this reference range may vary slightlybased on the information source.

Tachypneadenotesan abnormally rapid rate of breathing, often defined as a respiratory rateexceedingthe normal range for a person's age and physiological condition. The exact threshold for what is considered abnormal or tachypneic can vary, but a common reference point for adults is a breathing rate exceeding 20 breaths/min at rest.

Hyperpneainvolves an increased depth and rate of breathing, typicallylinkedto elevated oxygen demand or metabolic activity. Unlike hyperventilation, which often indicatesexcessive ventilation out of proportion to metabolic requirements, hyperpnea is a physiological response to factors like exercise, fever, or an increased metabolic rate. During hyperpnea, blood gasses remain within normal ranges.

Agonal breathingmanifests asirregular, gasping, or laboredbreaths, often resulting from anoxic brain injury. Agonal breathing is oftena critical sign ofa life-threatening emergency, such as a cardiac arrest. Healthcareprofessionals orfirst responders encountering a patient exhibiting agonal breathing should promptly initiate cardiopulmonary resuscitation and call for emergency medical assistance. This breathing pattern indicates the failure of the patient's cardiac and respiratory functions, underscoring the urgency of intervention.Swiftinterventionsignificantly enhances the chances of survival and recovery for these patients.

Apnea signifies a temporary cessation or absence of breathing, with 2 significant types: obstructive sleep apnea (OSA) and central sleep apnea.[13]

Hyperventilationdescribesan abnormal increase inbreathing rate and depth, leading to decreased CO2 concentration in the blood. Emotional stress, anxiety, panic attacks, fever, or certain medical conditions cantriggerhyperventilation. Additionally, chemoreceptor stimulation due to metabolic acidosis can drive this condition.

Hypoventilation isinsufficient ventilation incapable of removing adequate Co2 from the body. Hypoventilation can be a sign of various underlying medical conditions, including respiratory diseases (eg,COPD or sleep apnea), central nervous system disorders, certain medications (eg, opioids), or neuromuscular conditions impairing respiratory muscles.

Kussmaul respiration, named after the German physician Adolph Kussmaul, manifests asdeep, rapid, and difficult breathing. Thispattern occursin conditions causingmetabolic acidosis,[14]prompting the body toincrease the breathing depth and rate to expel carbon dioxide and reduce blood acid levels. Kussmaul respirations canresult fromdisorders like uremia or toxicingestions,such as alcohol and salicylates.

The Biot respiratory pattern, observed by French physician Camille Biot,comprises consistentdeepbreaths interspersed with apneaduetodamage to the ponsfrom stroke, trauma, or uncal herniation. With worsening pons insult, the pattern becomes irregular, eventually deteriorating to ataxic breathing. Additionally, opiate intoxication cantrigger the Biot pattern.[15]

Apneustic breathingis characterized by prolonged, gasping inhalations followed by extremely short and inadequate exhalations.This pattern results from upper pons injury, often due to stroke or trauma, signifying severe brain injury and a poor prognosis. Temporary induction can occur by the administration of ketamine.[16]

Central neurogenic hyperventilation is persistent hyperventilationresultingfrom head trauma, brain hypoxia, or inadequate cerebral perfusion, primarily due to the midbrain and upper pons damage. Central neurogenic hypoventilation, on the other hand, occurs when medullary respiratory centersdo notrespond appropriatelyto stimuli, occurring with head trauma, cerebral hypoxia, and narcotic suppression. Individuals with traumatic brain injury require careful management to avoid hyperventilation and hypoventilation. This ofteninvolves a combination of pharmacological, surgical, and medically induced coma interventions to address raised intracranial pressure.[17][18][19]

Disorders of respiration canlead tovarious respiratory diseases, which will be only brieflydiscussed here, as comprehensiveactivities on these topics are available. For example, in patients with COPD, theonset of hypercapnia is mainly associated with moreadvanced disease, althoughitsoccurrence isinconsistent amongpatients with similarlevels of airflow obstruction. Consequently, individualswithcomparable spirometric valuesmight exhibiteither the"blue bloater" or the "pink puffer" pattern, characterized by eucapnia and normal oxygen levels.[20][21]

Another example is the Ondine curse, which refers to alveolar hypoventilationdueto impaired autonomic ventilation control while maintaining normal voluntary breathing. Classically,individuals with this condition "forget to breathe" during sleep but maintain relatively normalbreathing patternswhile awake.[22][23]Congenital central hypoventilation syndrome, brainstem tumors or infarcts, and surgical manipulation of thesecond cervical segment of the spinal cord for intractable pain can cause the Ondine curse.[24]

Enhancing Healthcare Team Outcomes

Improving outcomes for patients with abnormal respirations necessitates a collaborative and interprofessional healthcare approach.A cohesive interprofessional teamcan enhance patient care, ensuretimely interventions, and optimizeresults. Healthcare professionals, including nurses, respiratory therapists, physicians, and advanced practitioners, must receive training to promptly recognize abnormal respiratory patternssuch as tachypnea, bradypnea, and apneustic and irregular breathing.

Effective communication among team members is crucial. Nurses, physicians, respiratory therapists, and specialists must promptly share observations, assessments, and recommendations.[25] Clear and concise documentation of patient assessments and respiratory status changes is essential. Respiratory therapists are crucial in assessing and managing patients with abnormal respirations, offering interventions such as administering oxygen therapy, performing respiratory treatments, and managing mechanical ventilation.

Enhancing healthcare team outcomes for patients with abnormal respirations relies on efficient communication, a collaborative approach, and a commitment to patient-centered care. Healthcare professionals fromdiversedisciplinesmust collaborate closelytoprovide the best possible care for these patients.

Review Questions

References

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: Disclosure: Lacey Whited declares no relevant financial relationships with ineligible companies.
: Disclosure: Muhammad Hashmi declares no relevant financial relationships with ineligible companies.
: Disclosure: Derrel Graham declares no relevant financial relationships with ineligible companies.