Just Breathe: Abnormal Breathing Patterns

The first words of my last blog post were “I’m still alive”. Well, I’m happy to report 470 days later that I am indeed “still alive”. I’ve had a bit of a hiatus since last. A lot has happened. I had a very memorable but next-level busy Chief year. I graduated from residency (shout out to Class of '15). Then I was fortunate enough to land my “dream job” as faculty member at Swedish First Hill. Hopefully I can get back into the groove of writing more now. If not, my next post might be sometime in 2016 (actually, it’s highly likely it’ll be in 2016).

Speaking of staying alive, sometimes the only thing you can do to keep living is to continue to just breathe. It's a bit of a played out sentiment that you're likely to see on a motivation poster featuring a kitten. But sometimes it can take on more like a Pearl Jam concert in Seattle. Occasionally that breathing can be an indication for what’s going on beneath the surface. A sigh. A deep breath. They all mean something. But today I'm looking into different types of breathing patterns, what they look like, and what could they potentially represent.

Before we look into abnormal patterns of breathing we should probably go back to year two of medical school and review exactly what happens with normal breathing patterns.  Feel free to skip the next two paragraphs if it’s old hat to you. When you take a deep breath in, air travels down your upper airway down to your lower airway. The upper airway serves as a filter for various particles in addition to humidifying and warming. Once the gases reach the lower airway it’s primarily about gas exchange. You want the oxygen. You don't want the carbon dioxide. Remember that the lungs have a dual blood supply. You have your pulmonary circulation, which sends deoxygenated blood through the pulmonary arteries to your lungs. Once at the lungs, gas exchange occurs at the capillary bed and sends oxygenated blood back to the heart via the pulmonary vein. On the other end you have your bronchial arteries that arise from the descending aorta to supply blood to your lung parenchyma.That’s the basics about blood supply.

How about the mechanism for getting the air in and out of the lungs? Respiration is controlled by a group of muscles – “the muscles of respiration”. Your diaphragm is the major player in this along with the accessory muscles (sternocleidomastoid, scalenes, and intercostals – aka the muscles we look at when evaluating for retractions). These muscles will help expand the lung which creates a negative intra-thoracic pressure gradient that helps bring the air down to the lower respiratory tract. Once you finish that breath you take in your vital capacity (remember VC + RV = TLC) and enter expiration. Expiration is a passive process which is essentially a function of the elastic recoil of the lung and chest wall.

All right. Out with the normal, in with the abnormal.

*Disclaimer: Some of the videos below don't have explicit patient approval listed by the publisher and others may be disturbing to watch. Please watch at own discretion*



Eponym Source: Old white guy in the late 19th century writing about diabetic coma.

Otherwise known as “air hunger”, key findings in Kussmaul respirations are RAPID and DEEP labored breathing with an urge to breath deeply.  The rate can be anywhere from slow, normal, or fast. This is due to the patient having metabolic acidosis. When you have low bicarbonate in the blood you will try to compensate for it in the acute period by “blowing off” more carbon dioxide. So with the onset of hyperventilation your ABG will normally show a metabolic acidosis with attempted compensatory respiratory alkalosis. The most common scenario to see Kussmaul respirations is indeed in DKA like the video depicts but it can happen in any scenario where you have a patient with metabolic acidosis. Fun fact: you can reproduce the effect, to a degree, by rapidly breathing in the air in a recently-emptied plastic soft drink bottle which contains an elevated amount of carbon dioxide.



Eponym Source: Two old white guys in the 19th century who described the breathing of a 60 year old man with CHF and stroke.

Also known as “periodic respiration”, Cheyne-Stokes (CS) respirations are characterized by a gradual hyperpnea followed by gradual hypopnea and eventually a period of apnea. In other words, the patient will gradually take deeper breaths (potentially faster as well) then will slowly take more shallow breaths until they reach a period where they don’t breath. The entire cycle takes anywhere between 30 seconds to 2 minutes and the apnea portion will normally last anywhere from 10-20 seconds. The mechanism behind CS respirations is that the apnea (caused by a number of etiologies) will lead to a build up of carbon dioxide which then leads to a disporportionate compensatory hyperventilation which then leads to the apneic phase again. This type of breathing pattern can be seen in CHF, strokes (or any other CNS insult), hyponatremia, carbon monoxide poisoning (important for the cold winter months), excessive morphine dosages, syncope and coma. Most notably, CS respirations are sometimes seen in patients who near death.



Eponym Source: Old white guy in the 19th century who wrote of a 16 year old patients with TB meningitis.

Biot respirations can be thought of as the atrial fibrillation of breathing. The correct definition is a breathing pattern of markedly variable tidal volumes and random apneas with no regularity. Occasionally you will see Biot respirations described as regular, rapid, shallow breaths followed by apnea but that’s really more of a definition of “cluster breathing”. Biot respirations are seen more often in CNS insults such as stroke or trauma. It can also be occasionally seen with chronic opiate use as well.



Many people will go through life never to know their true purpose. Fortunately for these three men, they found their calling and it was to film the next three videos. These thespians offer a tour de force portraying agonal breathing. I found it hard to rank these but I believe I have accumulated enough objective differences to find a true winner.

In third place is Maroon shirted man in “Nice Rug, Bad Drugs” where he depicts a struggling Persian rug salesman who overdoses on heroin and subsequently incurs an intracranial hemorrhage after falling from a stack of rugs late at night. I put this one in third place since there was no footage from a standing position to the agonal breaths. It’s well known in the agonal breathing youtube video community that a proper depiction will always show the moments leading up to the event. I do think he offers a unique perspective though as his breaths contain a substantial amount of phlegm. Something the other actors fail to provide.


It was a close battle for first place but the runner up goes to WA Gaspen for his performance in “Extinguishing Life”. The older gentleman offers a complete picture from carrying the extinguishers to the fall and subsequent agonal breaths. Unfortunately, I thought his fall was a bit soft as he braced quite heavily with his left hand. In addition, his breaths although quite dramatic complete with exaggerated mouth movements, was a bit premature. He begins these breaths almost immediately after hitting the ground. One would expect a bit more of a tempered approach by such a veteran.

And the winner is…

Ron Straight in “Blue Wall, Blue Shirt, Blue Face”. A quick google search shows that Ron has been a paramedic and teacher in Vancouver, CA for 30 years. Without a doubt, Ron’s entire life built up to this exact moment where he seized the spotlight and delivered a memorable performance. Ron played a decorated veteran who took up playing the blues in New Orleans. While waiting for his moment to finally take the stage, Ron succumbed to an untimely death. We all remember his final words in the film, “I just want to sing the blues. It doesn’t mean I’m blueee…. *gurgle*” (not depicted) He sealed the deal with his heart wrenching 6 second seizure after falling to the floor with abandon.

Honestly, after watching those three videos you can get a good sense of what agonal breaths entail. They can be quite variable but will typically have gasping, occasional myoclonic jerks, episodes of apnea and labored breathing with no particular sequence. This can be seen in cardiac arrest/cardiogenic shock as well as strokes or trauma that damage the medulla oblongata. Definitely a poor prognosis when you see this type of breathing and you should probably be less focused on the breathing when you encounter it and more on the impending catastrophe that is likely occurring.

One thing I didn't write about was treatment. The reason is that the treatment will always be the same. Whenever you come across an abnormal breathing pattern it's most likely a response to what's happening internally. Treatment will always be to correct the internal disturbance (CNS, cardiac, metabolic, etc).

So that's abnormal breathing in a nutshell. Just another reminder that there's always more going on than what you can see on the surface. Also that you're never too old to pursue your dreams. Just look at the three guys above.

Shameless Plug: If you're in the Seattle area and have nothing to do on December 11th come check out our residency band, Plan B, as we do a benefit show to help raise money for our Global Health Program! Click here for the Facebook invite. If you can't make it consider donating to the program found at the facebook event page. Thanks!