Respiratory Dysrhythmias in Patients With Tardive Dyskinesia

doi:10.1378/chest.105.1.203

Chest

Volume 105, Issue 1, January 1994, Pages 203-207

https://doi.org/10.1378/chest.105.1.203 Get rights and content

Tardive dyskinesia (TD) is a disorder characterized by abnormal involuntary movements and associated with neuroleptic therapy. To determine whether the respiratory muscles are involved in this condition, we compared the breathing pattern of ten patients with TD with ten patients with chronic schizophrenia receiving neuroleptic therapy without evidence of TD, and ten age-matched normal control subjects during resting tidal breathing, forearm pronation-supination (a maneuver designed to elicit the abnormal movements of TD), and breathing to a set frequency. Breathing patterns were also assessed in seven patients with TD during a progressive incremental exercise test and an overnight polysomnogram. Patients with TD had an irregular tidal breathing pattern, with a greater variability in both tidal volume and time of the total respiratory cycle (TTOT). Both groups of patients receiving neuroleptic therapy had a rapid shallow breathing pattern when performing forearm pronation-supination compared with control subjects. There were no differences between any of the subject groups when breathing to a set frequency. The patients with TD had a normal response to progressive exercise and inspiratory time and TTOT values were less variable during non-rapid eye movement sleep compared with wakefulness. We conclude that patients with TD have irregular rapid shallow breathing which is less variable during sleep and does not limit their exercise performance.

Section snippets

Subjects

Ten patients with chronic schizophrenia and TD secondary to neuroleptic therapy, ten age-matched patients with chronic schizophrenia and no evidence of TD, and ten age-matched normal control subjects were recruited. Both groups of patients with chronic schizophrenia had received neuroleptic therapy for at least 2 months prior to the study. Patients were excluded if they had significant cardiopulmonary disease or a previous or family history of a movement disorder other than TD. Neuroleptic

Test Data

Details of the anthropometric data, spirometry data, neuroleptic therapy dose and duration, and clinical scoring for TD and RD are presented in Table 1 for control subjects (group 1) and patients without (group 2) and with (group 3) clinical evidence of TD. Age, sex, and spirometry results were not different between the groups. The average and cumulative doses of neuroleptic therapy were not different between patient groups, but the duration of neuroleptic therapy was longer in patients with TD

Discussion

This study demonstrates that RDs can be identified in unselected patients with TD, that these dysrhythmias diminish with sleep, and that they do not limit exercise performance. Furthermore, some patients receiving neuroleptic therapy without obvious TD also have an abnormal breathing pattern during certain circumstances.

Weiner and associates⁷ described an association between RDs and TD. Three patients receiving long-term neuroleptic therapy had frequent involuntary grunts and gasps with

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The greater risk of lung disorders, including pneumonia and chronic obstructive pulmonary disorder (COPD), has been mentioned previously (Sokal et al., 2004; Chafetz et al., 2005). High rates of cigarette use, poor self-care and diet (Brown et al., 2000), use of antipsychotics that may cause respiratory irregularities (Nishikawa et al., 1992; Wilcox et al., 1994), and respiratory problems arising from neuroleptic malignant syndrome (Aruna and Murungi, 2005) may all contribute to the development of lung diseases. Patients with schizophrenia were independently associated with greater risks of intensive care unit admission, acute respiratory failure, and mechanical ventilation.
Patients with schizophrenia could have a higher risk of mortality. We compared the risk of mortality and the years of potential life lost (YPLL) associated with various causes of death between patients with schizophrenia and the general population. A total of 4,298 patients with schizophrenia were included. The cohort was linked to the Taiwan Death Register between 1998 and 2010 using personal identification numbers, which showed 367 patients with schizophrenia had died by the end of 2010. The standard mortality ratios (SMRs) and YPLL were analyzed by age, sex and cause of death. The overall SMR was significantly higher in patients with schizophrenia. Suicide had the most significantly greater SMR, and the SMRs for physical illnesses, accidents and injuries were all significantly greater in patients with schizophrenia. Suicide had the largest YPLL/deaths among all causes of mortality in patients with schizophrenia. Suicide had the most significantly greater risk of mortality among patients with schizophrenia as compared with the general population. Patients with schizophrenia are highly vulnerable in terms of increased mortality and require special attention.
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This respiratory pattern is characterized by irregular tidal breathing, causing hyperventilation at times and hypoventilation at other times, producing greater variability in the tidal volume as well as the time length of the total respiratory cycle. In general, classic TD patients with respiratory dysrhythmias have rapid, shallow breathing, often wrongly attributed to anxiety, sometimes associated with shortness of breath and compromised exercise performance [53]. In one report, two patients were noted to have esophageal dyskinesias confirmed by esophageal contrast radiography and esophageal manometry [54].
Tardive syndromes are a group of hyperkinetic and hypokinetic movement disorders that occur after some delay following exposure to dopamine receptor blocking agents such as antipsychotic and anti-emetic drugs. The severity of these disorders ranges from mild to disabling or even life-threatening. There is a wide range of recognized tardive phenomenologies that may occur in isolation or in combination with each other. These phenomenologies include stereotypy, dystonia, chorea, akathisia, myoclonus, tremor, tics, gait disorders, parkinsonism, ocular deviations, respiratory dyskinesia, and a variety of sensory symptoms. Recognition of the various tardive phenomenologies may not only lead to early diagnosis but also to appropriate therapeutic intervention. This review focuses on the diagnosis and clinical course of tardive syndromes and how to distinguish between the various phenomenologies as well as how to differentiate them from other, similar but etiologically different, movement disorders.
Nonprimary dystonias
2011, Handbook of Clinical Neurology
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Lateral deviation of the spine was the reason for the term “Pisa syndrome.” Involvement of the abdominal wall and the respiratory motor system can produce abnormal breathing patterns which may look alarming but do not cause medical problems (Weiner et al., 1978; Chiang et al., 1985; Yassa and Lal, 1986; Wilcox et al., 1994). Dystoniogenic drugs, almost all of which are DRBA (Table 38.2), are used as antipsychotics, antiemetics, and antidepressants.
Dystonias can be classified as primary or secondary, as dystonia-plus syndromes, and as heredodegenerative dystonias. Their prevalence is difficult to determine. In our experience 80–90% of all dystonias are primary. About 20–30% of those have a genetic background; 10–20% are secondary, with tardive dystonia and dystonia in cerebral palsy being the most common forms. If dystonia in spastic conditions is accepted as secondary dystonia, this is the most common form of all dystonia.
In primary dystonias, the dystonic movements are the only symptoms. In secondary dystonias, dystonic movements result from exogenous processes directly or indirectly affecting brain parenchyma. They may be caused by focal and diffuse brain damage, drugs, chemical agents, physical interactions with the central nervous system, and indirect central nervous system effects. Dystonia-plus syndromes describe brain parenchyma processes producing predominantly dystonia together with other movement disorders. They include dopa-responsive dystonia and myoclonus-dystonia. Heredodegenerative dystonias are dystonic movements occurring in the context of other heredodegenerative disorders. They may be caused by impaired energy metabolism, impaired systemic metabolism, storage of noxious substances, oligonucleotid repeats and other processes. Pseudodystonias mimic dystonia and include psychogenic dystonia and various orthopedic, ophthalmologic, vestibular, and traumatic conditions.
Unusual manifestations, unusual age of onset, suspect family history, suspect medical history, and additional signs may indicate nonprimary dystonia. If they are suspected, etiological clarification becomes necessary. Unfortunately, potential etiologies are legion. Diagnostic algorithms can be helpful.
Treatment of nonprimary dystonias, with few exceptions, does not differ from treatment of primary dystonias. The most effective treatment for focal and segmental dystonias is local botulinum toxin injections. Deep brain stimulation of the globus pallidus internus is effective for generalized dystonia. Antidystonic drugs, including anticholinergics, tetrabenazine, clozapine, and gamma-aminobutyric acid receptor agonists, are less effective and often produce adverse effects. Dopamine is extremely effective in dopa-responsive dystonia. The Bertrand procedure can be effective in cervical dystonia. Other peripheral surgery, including myotomy, myectomy, neurotomy, rhizotomy, ramizectomy, and accessory nerve neurolysis, has largely been abandoned. Central surgery other than deep brain stimulation is obsolete. Adjuvant therapies, including orthoses, physiotherapy, ergotherapy, behavioral therapy, social support, and support groups, may be helpful. Analgesics should also be considered where appropriate.
Epilepsy, Sleep, and Sleep Disorders
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Determine the risk associated with schizophrenia for common pulmonary illness (pneumonia and chronic obstructive pulmonary disorder (COPD)) during the last year of life.
Inpatient decedents in Veterans (VA) hospitals in 2002 (N = 27,798) were identified. Logistic regression modeled diagnosis of pulmonary illness in either the final year or final admission as a function of schizophrenia, smoking history and other covariates.
Among decedents, 943 (3%) had schizophrenia, 3% were women, most were white (76%) or African–American (18%), and average age at death was 72.4 years (SD 11.5). Three-fifths received VA outpatient care in the year prior to death. Among those with schizophrenia, only two-fifths had outpatient care. Pneumonia was more common among schizophrenia patients (38% vs 31%) as was COPD (46% vs 38%). In models controlling for history of smoking and other covariates, schizophrenia was a risk factor for pulmonary disease in the last year of life (OR = 1.9, 95% CI 1.6–2.2) but less so for final-stay pulmonary disease (OR = 1.5, 95% CI 1.3–1.7).
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Citation Excerpt :
These include segmental myoclonus, such as palatal myoclonus [234,235] or diaphragmatic flutter [236–238], and paroxysmal dystonia [239]. Respiratory dyskinesias also may be the manifestation of neuroleptic-induced dyskinesias and may or may not persist during sleep [240–243]. These should be differentiated from unusual nocturnal seizures that present with primarily or exclusively respiratory symptoms [244–246].

View all citing articles on Scopus

: Supported by the British Columbia Lung Association.

: Dr. Wilcox is a British Columbia Health Research Foundation Scholar.

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Chest

Clinical Investigations: MiscellaneousRespiratory Dysrhythmias in Patients With Tardive Dyskinesia

Section snippets

Subjects

Test Data

Discussion

Psychosomatics

Tardive dyskinesia: current clinical issues

Neurology

Drug induced and other orofacial-cervical dyskinesias

Ann Intern Med

Tardive dyskinesia: review and update

Am J Psychiatry

A study of facial dyskinesia in a mental hospital population

Br J Psychiatry

A survey of tardive dyskinesia in psychiatric outpatients

Am J Psychiatiy

Dyskinésie tardive post-neuroleptique

Laval Med

Respiratory dyskinesias: extrapyramidal dysfunction and dyspnea

Ann Intern Med

The irregularly irregular pattern of respiratory dyskinesia

Chest

Respiratory dyskinesia: review and case reports

J Clin Psychiatry

The respiratory components of tardive dyskinesa

Biol Psychiat

Tardive dyskinesia as a life-threatening illness

Am J Psychiatry

Clinical Investigations: Miscellaneous
Respiratory Dysrhythmias in Patients With Tardive Dyskinesia