The neurology of acutely failing respiratory mechanics

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Respiratory mechanics can become impaired in rapidly evolving neurologic disorders. Three mechanisms (weakness of the respiratory pump, inability to open the airway tract, and a poor cough) combine to create a critical condition with accelerating degrees of severity. Neurologists may see subtle findings (eg, shallow, rapid breathing and halting speech) or far more obvious presentations (dysphonia, pooling secretions, and hypoxemia), but there is an expectation that each patient requires urgent action and preemptive admission to an intensive care unit (ICU), often to assist ventilation.
Respiratory mechanics involve chest wall integrity and flexibility of movement, but forces involved in breathing—pulling in air and changing lung volume—are muscles of the pharynx, larynx, diaphragm, spine, and neck. The bulbar musculature maintains the architecture of a patent airway conduit, with abdominal wall and internal intercostal muscles needed to produce an effective cough. Acute dysfunction with a neural trajectory from brainstem to muscle may change respiratory mechanics.1 This review provides a practical assessment and offers guidance in the management of acutely failing respiratory pump function.
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