What it Looks Like: Agonal Respirations

See also what Jugular Venous DistentionSeizures, and Cardiac Arrest and CPR look like

Education and experience are both important to making a well-rounded provider, and each of the two have distinct advantages. Perhaps the greatest advantage of experience is that it gives you the best ability to recognize situations you’d otherwise only know by description or by photograph.

Nowadays, though, with the Wonders of Modern Technology, we have some tools that can help bridge this gap. Experience is still essential — but there’s no reason that the first time you see a seizure or cyanosis should be in a situation with real stakes.

So let’s go through some of the common medical events and conditions we talk about, learn about, but may not truly know the presentation of until we encounter it.

Today, it’s:

 

Agonal Respirations

Agonal respirations are an inadequate pattern of breathing associated with extreme physiological distress, particularly periarrest states (that is, it is usually seen just prior to cardiac arrest, as well as during and for some time after). Although not always seen during arrest, it is not uncommon, and there is some evidence that it may be associated with better outcomes than arrests without agonal breathing. Whatever the case, it can easily be confused for ordinary respiration, leading to the mistaken impression that the “breathing” patient must also have a pulse; this confusion is part of why the American Heart Association no longer recommends checking for breathing as part of layperson’s CPR.

As for healthcare providers, whether we’re able to put the label of “agonal” on it or not, we should be able to recognize from the rate and depth that this is not adequate respiration to sustain oxygenation, and ventilatory assistance (as well as a check of hemodynamic status) is in order. But recognizing the specific nature of this breathing can be a very useful red flag to set your “code” wheels in motion.

Here are a few simulated examples, performed by medical actors. They range in presentation and context.

Finally, here’s a treat — this is a video of a real-life cardiac arrest at a beach in Australia. Starting after the first shock, from 2:39 onward, you can see a great example of agonal breathing. The rest of the video is also a nice example of an honest code being worked in the field — not perfect, but real. (For bonus points, how could their CPR and other treatment have been improved?)

(Thanks to Dave Hiltz for inspiring today’s topic.)

Comments

  1. Nice code and great real-life agonal respirations…..compressions should of and need to be faster though. While preparing that AED they should of been doing a minimum of 100/min compressions. Ventilations are nice, but it does nothing if there’s no pumping action (compressions) to get the oxygen round and round. Compressions first, ventilations, and when that AED is attached back off and let it interpret a rhythm. As soon as that first shock was administered then CPR should of been immediately re-started.

    Remember, agonal respirations is respiratory arrest and if there is no palpable pulse, it’s cardiac arrest and CPR needs to be started with good-quality compressions. Re-assess every 2 min.

    • Nicely put! I’m not sure when that video was taken, but it’s obviously a few years old at least, and some elements like the compression rate may have been more appropriate at the time. Nowadays I’d like to see faster compressions and much, much less time off the chest. But all’s well that end’s well and you do what you can with what you’ve got.

      For what it’s worth, though, for an arrest presumably of respiratory (post-drowning) etiology, a traditional ABC approach with due consideration to ventilation makes sense to me. You still need great compressions, but if — for instance — the patient was found with lay responders doing compression-only CPR, I would like to get some breaths in before shocking.

  2. that is truly an honest code being worked.

  3. Peter Jensen says:

    Shocking and embarrasing to see that CPR and especially compressions are delayed for such a long time. These people are life guards!?

    Pete Jensen, MD

  4. I would like to know why a patient had clear cut agonal breathing yet became conscious on his own about 5 min later? My father has CHF w/ pacemaker/defib (biventricular failure, a-fib, backflow) and has been at the hospital ER 3xs due to CHF getting worse. Oct: dizzy spell while alone, fell and fractured 3 ribs. Nov. severe CHF w/ pitted edema, pneumonia, pulmonary edema. Sent home after water was taken off. Now Dec–this fainting/agonal episode.

    The last one with agonal breathing, he answered the door, got a little unsteady (he always says he’s dizzy), then turned, hit the door and slid down into a dead stare and did exactly what video 2 and 3 did. I called 911 immediately and about 5 min later he came to on his own. He was unsteady and I insisted he be transported. They noticed the arrhythmias in the ambulance (but he always runs high PVCs in the ER).

    Not one doctor there acknowledged the agonal breathing. They put dyspenia and synoscope. Diagnosis? Orthostatic hypotension. It seems VERY odd to me that something of agonal breathing is due to hypotension.

    I know this isn’t a med advice. I just would like a clear answer as to what happened there and possibilities why. I thougth w/ no intervention (the defib did not go off) he was in full fledged cardiac arrest and was dying in front of me. It was the most horrific thing I’ve seen in my life.

    • LK,

      That sounds terrifying. I’m sorry you had to see that happen.

      I’d hate to try to weigh in without all the particulars, and (frankly) without more letters behind my name. Five minutes of unconsciousness on the ground does seem very unusual for pure orthostatic hypotension, but stress can sometimes stretch our perception of time in these cases (I have been to very few syncopal episodes where bystanders reported the 1-2 seconds of unconsciousness that probably actually occurred). Did they interrogate the pacemaker’s memory at the hospital?

      • Yes. Nothing in detail beyond his defib didn’t go off. I paniced and totally forgot CPR and was worried with his prior CABG and pacemaker I would injure him. I figured if it was arrest, his defib would either kick in or it’s his time to go. Just call 911 and have them handle it. Chicago Fire Dept. was great (dispatch–not so much).

        I too have orthostatic hypotesnion and get faint/dizzy spells (white outs) but I have never had breathing stopped. So this is all very confusing.

        I understand with your medical training and expertise but still, it just feels like I’m getting a dismissal given that he’s 80 w/ all of these health issues. I firmly understand that his outcome for survival isn’t great beyond 5 years. His ejection is 35%, depressed since my mom passed in April, etc. But I just wish they give it to me straight. He’s very stubborn/’refusing help regarding living with me, assisted living, or even a medi-alert alarm.

        I also was a little suprised they didn’t do any neurological monitoring seeing that he turned blue then sheet white. His hands are always blue to dead-grey. I know that he’s getting very little circulation to his extremities and again, the whole agonal breathing just had me concerned for impact to the brain. They did basic response testing to see if a stroke happened. To me, he sounds slightly slurry and drools more since the episode but he says he’s ok. I mean, he is 80 so I guess it’s all relative too.

        Thank you for your response. Here’s hoping that all will remain peaceful in 2013.

        • LK, it sounds like you’re looking for a better explanation of what happened and a straight-shooting talk about risks. Have you considered looking for a second opinion from an outside physician?

          In some cases, people have also had good results by writing to department heads or the like (oversight or supervisory positions) with their concerns and what they’re looking for. The goal is to make it clear that you’re just looking for information, rather than pursuing a lawsuit, because that’s always the first thing their mind will go to. (Indeed, it still might be, and when it does, people tend to clam up… but hospitals are starting to understand that this just antagonizes people more.)

  5. thanks for that informations. that’s something that we all should know.

  6. I was also wondering why CPR wasn’t started sooner and the rate was really slow. They were lucky to get him back.

    • We’d certainly like to see more aggressive compressions in a high-performance system nowadays. But for the time this was filmed, I’d call this a pretty good and pretty professional code for a real-life (not rehearsed, and in fact quite unexpected) clinical situation.

  7. Jellojuggler says:

    I’m an RN in a jail and I just did rescue breathing for someone with agonal respirations. We were told he just passed out, when we reached him he was unresponsive but with a strong pulse. At first his respirations just looked a little weird, we put on the pulse oximeter and it read 38% percent! His breathing began to look a lot video 1 above. We quickly got our O2 out and somewhat clumsily hooked it all up, delivered rescue breaths with O2 inlet and his O2 pretty quickly went up to 95%. Then the paramedics came, intubated and took him on his way. I don’t know how it all turned out yet!

    • Strong work! Nice job checking the pulse quickly to determine which way things needed to proceed. Breathing for someone who’s not breathing is one of the easiest ways to save a life!

  8. Great article.

Trackbacks

  1. [...] I went about seeing other patients in the department, but I stopped in the room a couple of times to see what was happening. After 15 minutes, the picture changed. The patient reverted to his blank stare. His eyes were fixed on the wall across the room. His air movement steadily diminished as his respirations became more and more agonal. [...]

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