Rapid shallow breathing

[loveumms]

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Interesting case yesterday - still don't know the cause of the rapid breathing.

Middle aged man for I&D of toe ulcer. Patient was a poorly controlled DM II however, glucoses were in the 190-250 range. He comes into the OR and is crying b/c of the situation. We put him to sleep; standard induction (fent, propofol/lidocaine). Give some dilaudid up front b/c case is scheduled for <1 hour. 20 minutes after induction, pt breathing at 42 with Tv in the low 300s. Give another 250 of fentanyl in 50-100mcg increments. Cannot stop the breathing. ETCO2 in the low 30s.

I thought, well maybe he is going into DKA and has Kussmal breathing but, that is usually deep rapid breathing. It was really strange - anyone have any thoughts or had a similar case.

 

[jwk]

Interesting case yesterday - still don't know the cause of the rapid breathing.

Middle aged man for I&D of toe ulcer. Patient was a poorly controlled DM II however, glucoses were in the 190-250 range. He comes into the OR and is crying b/c of the situation. We put him to sleep; standard induction (fent, propofol/lidocaine). Give some dilaudid up front b/c case is scheduled for <1 hour. 20 minutes after induction, pt breathing at 42 with Tv in the low 300s. Give another 250 of fentanyl in 50-100mcg increments. Cannot stop the breathing. ETCO2 in the low 30s.

I thought, well maybe he is going into DKA and has Kussmal breathing but, that is usually deep rapid breathing. It was really strange - anyone have any thoughts or had a similar case.

What kind of meds is he on at home?

Is he asleep? (how do you know?) Agent? MAC, BIS?

Did you actually check a blood sugar pre-op? (If not, why not?) That range doesn't really tell me that much, and wouldn't raise that many eyebrows - it's high, but not that high that we'd even consider cancelling surgery.

 

[fakin' the funk]

Interesting case yesterday - still don't know the cause of the rapid breathing.

Middle aged man for I&D of toe ulcer. Patient was a poorly controlled DM II however, glucoses were in the 190-250 range. He comes into the OR and is crying b/c of the situation. We put him to sleep; standard induction (fent, propofol/lidocaine). Give some dilaudid up front b/c case is scheduled for <1 hour. 20 minutes after induction, pt breathing at 42 with Tv in the low 300s. Give another 250 of fentanyl in 50-100mcg increments. Cannot stop the breathing. ETCO2 in the low 30s.

I thought, well maybe he is going into DKA and has Kussmal breathing but, that is usually deep rapid breathing. It was really strange - anyone have any thoughts or had a similar case.

Just based on the fact you gave him 250mcg of fentanyl pretty quickly and couldn't get etCO2 up or apnea, I like opioid tolerance/dependence that the pt didn't tell you about here.

That his etCO2 is normal with a Ve of ~12L/min tells me his VCO2 and CO are high as well. This makes me think of sympathetic stimulation/hypermetabolic situations. Light anesthesia, EtOH/opioid withdrawal, MH, pheo, etc.

Your DKA (perhaps you mean HONK)/Kussmaul theory would require much, much lower etCO2 than what are stated. I remember a young DM1 pt who blew her PCO2 down to 6 with a glucose 800+.

 

[Bertelman]

Just based on the fact you gave him 250mcg of fentanyl pretty quickly and couldn't get etCO2 up or apnea, I like opioid tolerance/dependence that the pt didn't tell you about here.

That his etCO2 is normal with a Ve of ~12L/min tells me his VCO2 and CO are high as well. This makes me think of sympathetic stimulation/hypermetabolic situations. Light anesthesia, EtOH/opioid withdrawal, MH, pheo, etc.

Your DKA (perhaps you mean HONK)/Kussmaul theory would require much, much lower etCO2 than what are stated. I remember a young DM1 pt who blew her PCO2 down to 6 with a glucose 800+.

I'm not buying MH with a nml ETCO2, or pheo that's not hypertensive.

How about bacteremia/met acidosis.

 

[loveumms]

Glucose was 179 pre-op. Mac of 1.4 at one point.

Someone else took over and said they put him on pressure support and it slowed him down. I definitely thought about opioid tolerance of some sort too.

No temp elevation so unlikely MH and not hypertensive.


Was just very interesting.

 

[Idiopathic]

Glucose was 179 pre-op. Mac of 1.4 at one point.

Someone else took over and said they put him on pressure support and it slowed him down. I definitely thought about opioid tolerance of some sort too.

No temp elevation so unlikely MH and not hypertensive.


Was just very interesting.

your anesthetic will decrease tidal volumes and the patient will breathe rapidly to regulate their CO2. if you support their breathing, they will slow their rate down. i see this very frequently, usually not at a rate that high, but the principle is the same. i always try to support resps when patient spontaneously breathing, that way you can try to "dial them in"


also, if patient is breathing ETCO2 down to low 30s, they are not comfortable, and that necessitates more opiate, plain and simple. some studies have quoted the amount of fentanyl necessary to prevent response to surgical stimulation at 8-10 mcg/kg, which would have most people receiving 750-1000 mcg fentanyl upfront (even in opioid naive patients). we miss this many times because we paralyze patients, but every once in a while in a case like this you get surprised.

also cases like this are why i like dilaudid as a postoperative drug and fentanyl as an intraoperative drug. its easier to control, IMO.

 

[OB1🤙]

I've had cases like this from time to time that after much mental pontification including the thoughts already posted, I've just attributed to a pronounced volatile anesthetic breathing pattern, that for whatever reason a few select adults display.

 

[Idiopathic]

another thing to consider is that they increase their dead space ventilation with rapid breathing and so their ETCO2 does not reflect their PACO2

 

[IN2B8R]

your anesthetic will decrease tidal volumes and the patient will breathe rapidly to regulate their CO2. if you support their breathing, they will slow their rate down. i see this very frequently, usually not at a rate that high, but the principle is the same. i always try to support resps when patient spontaneously breathing, that way you can try to "dial them in"


also, if patient is breathing ETCO2 down to low 30s, they are not comfortable, and that necessitates more opiate, plain and simple. some studies have quoted the amount of fentanyl necessary to prevent response to surgical stimulation at 8-10 mcg/kg, which would have most people receiving 750-1000 mcg fentanyl upfront (even in opioid naive patients). we miss this many times because we paralyze patients, but every once in a while in a case like this you get surprised.

also cases like this are why i like dilaudid as a postoperative drug and fentanyl as an intraoperative drug. its easier to control, IMO.

And just what were they doing to those patients in such "studies"? Were the patients undergoing CABG's or simple, thirty minutes I&D's?😱 If practioners are out there pushing this much fentanyl for simple procedures (in opiate naive patients), then such practioners should be disposed of: opiods induced hyperalgesia is very much real. Opiods physical/psychological dependence is just downstream when such patients get discharged.... So anyone advocating such high dosing of narcs deserves further education.

 

[Idiopathic]

im not saying it applies to every case, and certainly not small cases, but it is an alternative viewpoint to consider when debating how much opiate to give. i frequently see residents wanting to beta block their patients 15 minutes into a case, when they have 1-2 mcg/kg of fentanyl on board and they are tachy/hyper during the early part of the case.

every patient is different, obviously you wouldnt give such high doses of fentanyl upfront without provocation, but higher than anticipated dose requirements shouldnt be written off, either.

 

[Idiopathic]

And just what were they doing to those patients in such "studies"? Were the patients undergoing CABG's or simple, thirty minutes I&D's?😱 If practioners are out there pushing this much fentanyl for simple procedures (in opiate naive patients), then such practioners should be disposed of: opiods induced hyperalgesia is very much real. Opiods physical/psychological dependence is just downstream when such patients get discharged.... So anyone advocating such high dosing of narcs deserves further education.

im also using this as a MAC-analogy. if you are paralyzing your patients, as many of us do, you may miss things like movement with incision, tachypnea, etc, that may be a sign of discomfort. i dont advocate high dose opiate for most cases, just another way to think about it

 

[gtb]

There was a useful (for me anyway) article last year in Anesthesiology about increased CO2 occurring in the perioperative setting.

http://journals.lww.com/anesthesiol...__Increased_End_tidal_Carbon_Dioxide_.29.aspx

You didn't mention the heart rate (or at least I didn't see anything about it), or anything about his outpatient medications (legal or illegal). These would help narrow the differential. In the case of tachycardia, thyroid storm hasn't been mentioned yet, sepsis was mentioned though. A blood gas would sort out your concern for DKA, but FTF pointed out that a lower EtCO2 would be expected. At a rate of 42'ish, I don't know that our gas analyzers would accurately measure End-tidal CO2, since the measurement algorithm requires a near-plateau just before inspiration, however I'm not sure about that.

 

[narcusprince]

Interesting case yesterday - still don't know the cause of the rapid breathing.

Middle aged man for I&D of toe ulcer. Patient was a poorly controlled DM II however, glucoses were in the 190-250 range. He comes into the OR and is crying b/c of the situation. We put him to sleep; standard induction (fent, propofol/lidocaine). Give some dilaudid up front b/c case is scheduled for <1 hour. 20 minutes after induction, pt breathing at 42 with Tv in the low 300s. Give another 250 of fentanyl in 50-100mcg increments. Cannot stop the breathing. ETCO2 in the low 30s.

I thought, well maybe he is going into DKA and has Kussmal breathing but, that is usually deep rapid breathing. It was really strange - anyone have any thoughts or had a similar case.

Was a blood gas sent?? This may shed a clue regarding the apparent hyperventilation.

 

[lobelsteve]

DISCLAIMER: Not an Anes.

Stupid question: What would a PE look like in data provided? ETCO2, TV?

 

[dhb]

DISCLAIMER: Not an Anes.

Stupid question: What would a PE look like in data provided? ETCO2, TV?

ETCO2 drops, TV should be unchanged except maybe in a huge PE where CO2 removal is compromised and O2 Sat would decrease depending on size of PE and FiO2 administered.

In the case presented opioid abuse by patient would be high on my list

 

[Idiopathic]

Interesting case yesterday - still don't know the cause of the rapid breathing.

Middle aged man for I&D of toe ulcer. Patient was a poorly controlled DM II however, glucoses were in the 190-250 range. He comes into the OR and is crying b/c of the situation. We put him to sleep; standard induction (fent, propofol/lidocaine). Give some dilaudid up front b/c case is scheduled for <1 hour. 20 minutes after induction, pt breathing at 42 with Tv in the low 300s. Give another 250 of fentanyl in 50-100mcg increments. Cannot stop the breathing. ETCO2 in the low 30s.

I thought, well maybe he is going into DKA and has Kussmal breathing but, that is usually deep rapid breathing. It was really strange - anyone have any thoughts or had a similar case.

also good to remember that these patients (type II, even insulin-requiring) typically do not go into DKA.

 

[IN2B8R]

im also using this as a MAC-analogy. if you are paralyzing your patients, as many of us do, you may miss things like movement with incision, tachypnea, etc, that may be a sign of discomfort. i dont advocate high dose opiate for most cases, just another way to think about it

Good points.... Yeah, straighten them residents out, please!😉

 

[fakin' the funk]

I've had cases like this from time to time that after much mental pontification including the thoughts already posted, I've just attributed to a pronounced volatile anesthetic breathing pattern, that for whatever reason a few select adults display.

👍

 

[fakin' the funk]

In the case of tachycardia, thyroid storm hasn't been mentioned yet, sepsis was mentioned though. A blood gas would sort out your concern for DKA, but FTF pointed out that a lower EtCO2 would be expected.

I specifically did not mention thyroid storm because it is ridiculous.

 

[fakin' the funk]

How about bacteremia/met acidosis.

I like it. You guys have probably noticed this hypermetabolic/septic physiology that happens after an hour or so of osteomyelitis washout/septic body part washout that has got to be from a mild SIRS thing happening. Once that endotoxin or LPS hits the circulation you get some TNF, IL-1, IL-6, metabolic activation, venodilation, histamine in the precapillary vessels, etc etc.

The pt in question is having a rotten toe washed out, so there ya go.

 

[epidural man]

I've had cases like this from time to time that after much mental pontification including the thoughts already posted, I've just attributed to a pronounced volatile anesthetic breathing pattern, that for whatever reason a few select adults display.

👍

I've seen it a few times - almost always with an LMA.

I don't think it has anything to do with opioids or pain or sepsis or any other physiologic problems - just an abnormally exaggerated response to a normal physiologic response to volatiles. Nimbex fixes the problem.

 

[nap$ter]

the older i get, the more i like "multifactorial".

had one guy for lipoma excision o/w healthy, thinnish, no vices.

minute ventilation on LMA throughout (30min) case = 14L = rr of 14 x 1000mL, etco2 35, normothermic, all other vitals normal, sevo at 2.2. nl breath sounds, spo2 99 great wave form.

resident gave 250ug fentanyl in divided doses - MV 14 x 1000mL = 14L.

slightly slow to wake (from fentanyl i wager), lma out, "i feel great" - huffed and puffed all the way to pacu. gradually began to look normal prior to discharge home. thought about drawing a gas or checking a cxr - but reasonable patient continued to report feeling "just fine", "i dunno why" taking such big breaths.

"multifactorial"

 

[gtb]

I specifically did not mention thyroid storm because it is ridiculous.

Sorry, why completely, absolutely out of the question?

 

[fakin' the funk]

Sorry, why completely, absolutely out of the question?

It's ridiculous just to throw in routinely with that "hypermetabolic" differential because:
a) it doesn't just HAPPEN to all-comers the way MH or sepsis can. it happens to people who were ALREADY hyperthyroid
b) it is ridiculously rare
c) in surgical patients, it almost always happens 1-3d postop. This is like putting MH at the start of a ddx of a hypermetabolic pt 12h out from some sort of wound washout. "Well it COULD happen postop!"