Kussmaul breathing

Kussmaul breathing is the rapid, deep, and labored breathing of people who have diabetic ketoacidosis. Ketoacidosis is a short term complication of diabetes caused by very high blood glucose levels accompanied by a high level of ketones in the blood. Ketoacidosis will only usually affect people with diabetes if they haven’t taken sufficient insulin. Diabetic ketoacidosis is a very dangerous condition and should be treated as an emergency. Kussmaul respirations were originally observed and described by Dr. Adolf Kussmaul in 1874 ¹. He made his observation in diabetic patients who were comatose and in the late stages of diabetic ketoacidosis. Dr. Kussmaul actually described it as “air hunger.”

Kussmaul respiratory pattern occurs due to increased tidal volume with or without an increased respiratory rate. Kussmaul breathing is a form of hyperventilation. Kussmaul breathing results from stimulation of the respiratory center in the brain stem by low serum pH. The effect is the lowering of the partial pressure of carbon dioxide in the alveoli, thereby compensating for metabolic acidosis. Initially, in acidosis, the respiratory pattern is rapid and shallow, but as the acidosis progresses, the inspirations become deeper. It is only in the later stages that true Kussmaul breathing are seen. Kussmaul respirations can be seen with any disorder that causes significant acidosis. Toxic ingestions, particularly alcohols, are another common cause of Kussmaul respirations. Salicylate toxicity is also a cause. Kussmaul breathing was also classically described in patients with uremia. Kussmaul breathing can also be seen in any disorder that results in lactic or ketoacidosis.

Kussmaul breathing evaluation

In the evaluation of dyspnea, a thorough history and physical exam are warranted with special attention to underlying and possibly reversible causes. Additional laboratory and radiologic evaluation can be useful in diagnosis and in guiding treatment. An ECG (electrocardiogram) may help your care team find a possible heart or lung problem. Pulse oximetry can provide information about oxygen saturation. Arterial blood gases can reveal the presence of acid-base disturbances, hypoxia, or abnormal partial pressures of carbon dioxide. Hemoglobin count can identify anemia. An abnormally high or low leukocyte count or an abnormal leukocyte differential may be suggestive of an infection.

Radiographic imaging, with such modalities as x-ray and computed tomography, can provide a great deal of information regarding the lung parenchyma, pleural space, pulmonary vasculature, and larger airway structures, as well as the bony elements of the thorax. Combined, the laboratory and radiographic information may help identify an underlying etiology of the dyspnea and as such can help guide disease-modifying and symptomatic treatment. However, as dyspnea is a subjective, multifactorial symptom, it may occur in the absence of any identifiable laboratory or radiographic abnormalities.

Diabetic ketoacidosis is usually diagnosed using blood and urine tests which measure the concentration of ketones in the blood or urine.

In addition to testing ketone levels , levels of potassium may also be measured as part of the treatment to check for signs of hypokalemia (low potassium levels). Potassium may be depleted as a result of excessive urination.

Kussmaul breathing treatment

Diabetic ketoacidosis

Diabetic ketoacidosis is a serious medical emergency. Without urgent treatment, this diabetes complication can lead to death. With adequate and rapid intervention and treatment, mortality rates are lowered to around 5%. If someone with diabetes displays the signs of ketoacidosis, the situation should be treated as an emergency

Treatment of diabetic ketoacidosis involves administering intravenous fluids to correct dehydration and to replace any salts that may be lost from the body during ketoacidosis through passing excessive quantities of urine.

Insulin is also required to instantly suppress the ketone bodies that the body manufactures.

If an infection has been the underlying causes of diabetic ketoacidosis, you will be given a sick day plan to help you take the right amount of insulin Close observation of the patient to quickly identify and prevent complications is essential and therefore you will usually be treated in hospital until your ketone levels have stabilised and you have returned to eating normally.

Alcoholic ketoacidosis

Alcoholic ketoacidosis typically responds to treatment with intravenous saline and intravenous glucose, with rapid clearance of the associated ketones due to a reduction in counter-regulatory hormones and the induction of endogenous insulin. Like in diabetic ketoacidosis, this is the first step in management because of the need for correction the hypovolemia/shock. Thiamine replacement is important in alcohol-related presentations including intoxication, withdrawal, and ketoacidosis; and should be initially done parenterally and after that maintained orally. Electrolyte replacement is critical. Potassium losses that occur through gastrointestinal (GI) or renal losses should be monitored and replaced closely as glucose in the replacement fluid induces endogenous insulin which in turn drives the extracellular potassium inside the cells. Also of paramount importance is monitoring and replacing the magnesium and phosphate levels which are usually low in both chronic alcoholism and prolonged dietary deprivation as in starvation.

Kussmaul breathing end of life

Opioids are considered a mainstay of treatment for dyspnea. The evidence is most robust regarding the use of immediate-release morphine. Opioids, via the mu opioid receptors, reduce the discomfort of air hunger but less the discomfort of the increased effort to breathe. It is theorized that morphine decreases spontaneous respiratory drive and the sensitivity of the central breathing center. Opioids may also affect cortical processing of dyspnea as they do in the setting of pain ².

The use of benzodiazepines reduces the anxiety often associated with dyspnea, but not the sensation of dyspnea ³.

Nebulized furosemide has some evidence of efficacy in patients with chronic obstructive pulmonary disease (COPD). It is thought to activate pulmonary mechanoreceptors. In animal models, inhaled furosemide increases the activity of pulmonary vagal stretch receptors ⁴.

Nebulized lidocaine or morphine has no evidence of benefit.

Dexamethasone may be useful to improve dyspnea in lung cancer patients or those with COPD ⁵.

Mirtazapine has been shown to have some beneficial effect in patients with chronic dyspnea ⁶.

Diuretics treat fluid overload in congestive heart failure, renal failure, and hepatic failure.

Beta-adrenergic agonists and muscarinic antagonists can reduce symptoms in advanced stages of the chronic obstructive pulmonary disease (COPD) ⁷.

Oxygen administration can improve dyspnea but only in patients with hypoxemia.

Non-pharmacologic therapies

To help with shortness of breath, try:

• Sitting up
• Sitting or sleeping in a reclining chair
• Raising the head of the bed or using pillows to sit up
• Leaning forward

Find ways to relax:

• Listen to calming music.
• Get a massage.
• Put a cool cloth on your neck or head.
• Take slow breaths in through your nose and out through your mouth. It may help to pucker your lips like you were going to whistle. This is called pursed lip breathing.
• Get reassurance from a calm friend, family member, or hospice team member.
• Get a breeze from an open window or a fan.

Cold air and the use of fans blowing air on the face can significantly improve dyspnea. Sensory afferents may mediate this effect in the second and third branch of the trigeminal nerve. Supplemental oxygen has only been shown to be useful in patients with hypoxia ⁸.

References

1. Whited L, Graham DD. Abnormal Respirations. [Updated 2019 Jul 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470309
2. Kwon JH, Kim MJ, Bruera S, Park M, Bruera E, Hui D. Off-Label Medication Use in the Inpatient Palliative Care Unit. J Pain Symptom Manage. 2017 Jul;54(1):46-54.
3. Simon ST, Higginson IJ, Booth S, Harding R, Weingärtner V, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev. 2016 Oct 20;10:CD007354
4. Barbetta C, Currow DC, Johnson MJ. Non-opioid medications for the relief of chronic breathlessness: current evidence. Expert Rev Respir Med. 2017 Apr;11(4):333-341.
5. Hui D, Kilgore K, Frisbee-Hume S, Park M, Tsao A, Delgado Guay M, Lu C, William W, Pisters K, Eapen G, Fossella F, Amin S, Bruera E. Dexamethasone for Dyspnea in Cancer Patients: A Pilot Double-Blind, Randomized, Controlled Trial. J Pain Symptom Manage. 2016 Jul;52(1):8-16.e1.
6. Lovell N, Bajwah S, Maddocks M, Wilcock A, Higginson IJ. Use of mirtazapine in patients with chronic breathlessness: A case series. Palliat Med. 2018 Oct;32(9):1518-1521.
7. Lilly EJ, Senderovich H. Palliative care in chronic obstructive pulmonary disease. J Crit Care. 2016 Oct;35:150-4.
8. Kako J, Morita T, Yamaguchi T, Kobayashi M, Sekimoto A, Kinoshita H, Ogawa A, Zenda S, Uchitomi Y, Inoguchi H, Matsushima E. Fan Therapy Is Effective in Relieving Dyspnea in Patients With Terminally Ill Cancer: A Parallel-Arm, Randomized Controlled Trial. J Pain Symptom Manage. 2018 Oct;56(4):493-500.