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Wijdicks EFM. Fast and Deep Breathing in Acute Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-01970-y. [PMID: 38561587 DOI: 10.1007/s12028-024-01970-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Eelco F M Wijdicks
- Neurocritical Care Services, Saint Marys Campus, Mayo Clinic Hospital, 200 First Street SW, Rochester, MN, 55905, USA.
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Jareonsettasin P, Zeicu C, Diehl B, Harper RM, Astin R. Inappropriate Ventilatory Homeostatic Responses in Hospitalized COVID-19 Patients. Front Neurol 2022; 13:909915. [PMID: 35785338 PMCID: PMC9240262 DOI: 10.3389/fneur.2022.909915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/19/2022] [Indexed: 11/15/2022] Open
Abstract
Background The clinical presentation of COVID-19 suggests altered breathing control - tachypnoea, relative lack of dyspnoea, and often a discrepancy between severity of clinical and radiological findings. Few studies characterize and analyse the contribution of breathing drivers and their ventilatory and perceptual responses. Aim To establish the prevalence of inappropriate ventilatory and perceptual response in COVID-19, by characterizing the relationships between respiratory rate (RR), dyspnoea and arterial blood gas (ABG) in a cohort of COVID-19 patients at presentation to hospital, and their post-Covid respiratory sequelae at follow-up. Methods We conducted a retrospective cohort study including consecutive adult patients admitted to hospital with confirmed COVID-19 between 1st March 2020 and 30th April 2020. In those with concurrent ABG, RR and documented dyspnoea status on presentation, we documented patient characteristics, disease severity, and outcomes at hospital and 6-week post-discharge. Results Of 492 admissions, 194 patients met the inclusion criteria. Tachypnoea was present in 75% pronounced (RR>30) in 36%, and persisted during sleep. RR correlated with heart rate (HR) (r = 0.2674), temperature (r = 0.2824), CRP (r = 0.2561), Alveolar-arterial (A-a) gradient (r = 0.4189), and lower PaO2/FiO2 (PF) ratio (r = −0.3636). RR was not correlated with any neurological symptoms. Dyspnoea was correlated with RR (r = 0.2932), A-a gradient (r = 0.1723), and lower PF ratio (r = −0.1914), but not correlated with PaO2 (r = −0.1095), PaCO2 (r = −0.0598) or any recorded neurological symptom except for altered consciousness. Impaired ventilatory homeostatic control of pH/PaCO2 [tachypnoea (RR>20), hypocapnia (PaCO2 <4.6 kPa), and alkalosis (pH>7.45)] was observed in 29%. This group, of which 37% reported no dyspnoea, had more severe respiratory disease (A-a gradient 38.9 vs. 12.4 mmHg; PF ratio 120 vs. 238), and higher prevalence of anosmia (21 vs. 15%), dysgeusia (25 vs. 12%), headache (33 vs. 23%) and nausea (33 vs. 14%) with similar rates of new anxiety/depression (26 vs. 23%), but lower incidence of past neurological or psychiatric diagnoses (5 vs. 21%) compared to appropriate responders. Only 5% had hypoxia sufficiently severe to drive breathing (i.e. PaO2 <6.6 kPa). At 6 weeks post-discharge, 24% (8/34) showed a new breathing pattern disorder with no other neurological findings, nor previous respiratory, neurological, or psychiatric disorder diagnoses. Conclusions Impaired homeostatic control of ventilation i.e., tachypnoea, despite hypocapnia to the point of alkalosis appears prevalent in patients admitted to hospital with COVID-19, a finding typically accompanying more severe disease. Tachypnoea prevalence was between 12 and 29%. Data suggest that excessive tachypnoea is driven by both peripheral and central mechanisms, but not hypoxia. Over a third of patients with impaired homeostatic ventilatory control did not experience dyspnoea despite tachypnoea. A subset of followed-up patients developed post-covid breathing pattern disorder.
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Affiliation(s)
- Prem Jareonsettasin
- Department of Clinical and Experimental Epilepsy, Queen Square Institute of Neurology, University College London, London, United Kingdom
- Division of Medical Specialties, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- *Correspondence: Prem Jareonsettasin
| | - Claudia Zeicu
- Department of Clinical and Experimental Epilepsy, Queen Square Institute of Neurology, University College London, London, United Kingdom
- Division of Medical Specialties, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Beate Diehl
- Department of Clinical and Experimental Epilepsy, Queen Square Institute of Neurology, University College London, London, United Kingdom
- Department of Clinical Neurophysiology, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Ronald M. Harper
- Department of Neurobiology and the Brain Research Institute, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Rónan Astin
- Division of Medical Specialties, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- NIHR University College London Hospitals Biomedical Research Centre, London, United Kingdom
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Neves Briard J, Beaulieu MC, Lemoine É, Beaulieu C, Dubé BP, Lapointe S. Central neurogenic hyperventilation in conscious patients due to CNS neoplasm: a case report and review of the literature on treatment. Neurooncol Pract 2020; 7:559-568. [PMID: 33014397 DOI: 10.1093/nop/npaa016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Central neurogenic hyperventilation (CNH) is increasingly reported in conscious patients with a CNS neoplasm. We aimed to synthesize the available data on the treatment of this condition to guide clinicians in their approach. Methods We describe the case of a 39-year-old conscious woman with CNH secondary to glioma brainstem infiltration for whom hyperventilation was aborted with hydromorphone, dexamethasone, and brainstem radiotherapy. We then performed a review of the literature on the treatment of CNH in conscious patients due to a CNS neoplasm. Results A total of 31 studies reporting 33 cases fulfilled the selection criteria. The underlying neoplasm was lymphoma in 15 (45%) and glioma in 13 (39%) patients. Overall, CNH was aborted in 70% of cases. Opioids and sedatives overall seemed useful for symptom relief, but the benefit was often of short duration when the medication was administered orally or subcutaneously. Methadone and fentanyl were successful but rarely used. Chemotherapy was most effective in patients with lymphoma (89%), but not glioma (0%) or other neoplasms (0%). Patients with lymphoma (80%) and other tumors (100%) responded to radiotherapy more frequently than patients with glioma (43%). Corticosteroids were moderately effective. Subtotal surgical resection was successful in the 3 cases for which it was attempted. Conclusion Definitive treatment of the underlying neoplasm may be more successful in aborting hyperventilation. Variable rates of palliation have been observed with opioids and sedatives. Treatment of CNH is challenging but successful in a majority of cases.
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Affiliation(s)
- Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Quebec, Canada.,Centre de recherche du CHUM, Quebec, Canada
| | | | - Émile Lemoine
- Department of Neuroscience, Université de Montréal, Quebec, Canada
| | | | - Bruno-Pierre Dubé
- Service de pneumologie, Centre hospitalier de l'Université de Montréal (CHUM), Quebec, Canada.,Centre de recherche du CHUM, Quebec, Canada
| | - Sarah Lapointe
- Service de neurologie, CHUM, QC, Canada.,Centre de recherche du CHUM, Quebec, Canada
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Williamson CA, Sheehan KM, Tipirneni R, Roark CD, Pandey AS, Thompson BG, Rajajee V. The Association Between Spontaneous Hyperventilation, Delayed Cerebral Ischemia, and Poor Neurological Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2016; 23:330-8. [PMID: 25846710 DOI: 10.1007/s12028-015-0138-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The frequency and associations of spontaneous hyperventilation in subarachnoid hemorrhage (SAH) are unknown. Because hyperventilation decreases cerebral blood flow, it may exacerbate delayed cerebral ischemia (DCI) and worsen neurological outcome. METHODS This is a retrospective analysis of data from a prospectively collected cohort of SAH patients at an academic medical center. Spontaneous hyperventilation was defined by PaCO2 <35 mmHg and pH >7.45 and subdivided into moderate and severe groups. Clinical and demographic characteristics of patients with and without spontaneous hyperventilation were compared using χ (2) or t tests. Bivariate and multivariable logistic regression analyses were conducted to examine the association of moderate and severe hyperventilation with DCI and discharge neurological outcome. RESULTS Of 207 patients, 113 (55 %) had spontaneous hyperventilation. Spontaneously hyperventilating patients had greater illness severity as measured by the Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), and SAH sum scores. They were also more likely to develop the following complications: pneumonia, neurogenic myocardial injury, systemic inflammatory response syndrome (SIRS), radiographic vasospasm, DCI, and poor neurological outcome. In a multivariable logistic regression model including age, gender, WFNS, SAH sum score, pneumonia, neurogenic myocardial injury, etiology, and SIRS, only moderate [odds ratio (OR) 2.49, 95 % confidence interval (CI) 1.10-5.62] and severe (OR 3.12, 95 % CI 1.30-7.49) spontaneous hyperventilation were associated with DCI. Severe spontaneous hyperventilation (OR 4.52, 95 % CI 1.37-14.89) was also significantly associated with poor discharge outcome in multivariable logistic regression analysis. CONCLUSION Spontaneous hyperventilation is common in SAH and is associated with DCI and poor neurological outcome.
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Affiliation(s)
- Craig A Williamson
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Kyle M Sheehan
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Renuka Tipirneni
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI, 48109, USA
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christopher D Roark
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA
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Monterrubio-Villar J, Mora-Encinas JP, Jiménez-Delgado JD, Almaraz-Velarde R. Hiperventilación central neurogénica en un paciente con encefalomielitis aguda diseminada posvacunal. Med Clin (Barc) 2015; 145:e23-4. [DOI: 10.1016/j.medcli.2015.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 01/27/2015] [Accepted: 02/05/2015] [Indexed: 10/23/2022]
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Khorooshi R, Asgari N, Mørch MT, Berg CT, Owens T. Hypersensitivity Responses in the Central Nervous System. Front Immunol 2015; 6:517. [PMID: 26500654 PMCID: PMC4595775 DOI: 10.3389/fimmu.2015.00517] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/22/2015] [Indexed: 12/29/2022] Open
Abstract
Immune-mediated tissue damage or hypersensitivity can be mediated by autospecific IgG antibodies. Pathology results from activation of complement, and antibody-dependent cellular cytotoxicity, mediated by inflammatory effector leukocytes include macrophages, natural killer cells, and granulocytes. Antibodies and complement have been associated to demyelinating pathology in multiple sclerosis (MS) lesions, where macrophages predominate among infiltrating myeloid cells. Serum-derived autoantibodies with predominant specificity for the astrocyte water channel aquaporin-4 (AQP4) are implicated as inducers of pathology in neuromyelitis optica (NMO), a central nervous system (CNS) demyelinating disease where activated neutrophils infiltrate, unlike in MS. The most widely used model for MS, experimental autoimmune encephalomyelitis, is an autoantigen-immunized disease that can be transferred to naive animals with CD4+ T cells, but not with antibodies. By contrast, NMO-like astrocyte and myelin pathology can be transferred to mice with AQP4–IgG from NMO patients. This is dependent on complement, and does not require T cells. Consistent with clinical observations that interferon-beta is ineffective as a therapy for NMO, NMO-like pathology is significantly reduced in mice lacking the Type I IFN receptor. In MS, there is evidence for intrathecal synthesis of antibodies as well as blood–brain barrier (BBB) breakdown, whereas in NMO, IgG accesses the CNS from blood. Transfer models involve either direct injection of antibody and complement to the CNS, or experimental manipulations to induce BBB breakdown. We here review studies in MS and NMO that elucidate roles for IgG and complement in the induction of BBB breakdown, astrocytopathy, and demyelinating pathology. These studies point to significance of T-independent effector mechanisms in neuroinflammation.
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Affiliation(s)
- Reza Khorooshi
- Department of Neurobiology Research, Institute for Molecular Medicine, University of Southern Denmark , Odense , Denmark
| | - Nasrin Asgari
- Department of Neurobiology Research, Institute for Molecular Medicine, University of Southern Denmark , Odense , Denmark ; Department of Neurology, Vejle Hospital , Vejle , Denmark
| | - Marlene Thorsen Mørch
- Department of Neurobiology Research, Institute for Molecular Medicine, University of Southern Denmark , Odense , Denmark
| | - Carsten Tue Berg
- Department of Neurobiology Research, Institute for Molecular Medicine, University of Southern Denmark , Odense , Denmark
| | - Trevor Owens
- Department of Neurobiology Research, Institute for Molecular Medicine, University of Southern Denmark , Odense , Denmark
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Neurologic complications of electrolyte disturbances and acid-base balance. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:365-82. [PMID: 24365306 DOI: 10.1016/b978-0-7020-4086-3.00023-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Electrolyte and acid-base disturbances are common occurrences in daily clinical practice. Although these abnormalities can be readily ascertained from routine laboratory findings, only specific clinical correlates may attest as to their significance. Among a wide phenotypic spectrum, acute electrolyte and acid-base disturbances may affect the peripheral nervous system as arreflexic weakness (hypermagnesemia, hyperkalemia, and hypophosphatemia), the central nervous system as epileptic encephalopathies (hypomagnesemia, dysnatremias, and hypocalcemia), or both as a mixture of encephalopathy and weakness or paresthesias (hypocalcemia, alkalosis). Disabling complications may develop not only when these derangements are overlooked and left untreated (e.g., visual loss from intracranial hypertension in respiratory or metabolic acidosis; quadriplegia with respiratory insufficiency in hypermagnesemia) but also when they are inappropriately managed (e.g., central pontine myelinolisis when rapidly correcting hyponatremia; cardiac arrhythmias when aggressively correcting hypo- or hyperkalemia). Therefore prompt identification of the specific neurometabolic syndromes is critical to correct the causative electrolyte or acid-base disturbances and prevent permanent central or peripheral nervous system injury. This chapter reviews the pathophysiology, clinical investigations, clinical phenotypes, and current management strategies in disorders resulting from alterations in the plasma concentration of sodium, potassium, calcium, magnesium, and phosphorus as well as from acidemia and alkalemia.
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