Biot’s respirations, also referred to as ataxic respirations, are a rare and highly abnormal breathing pattern characterized by complete irregularity in rate, rhythm, and depth. This respiratory pattern often signifies advanced neurologic compromise, most notably involving brain stem pathology, and is associated with a poor prognosis.

Clinical characteristics

• Completely irregular respiratory pattern

• Variable tidal volumes: alternating shallow and deep breaths

• Irregular pauses with no discernible cycle

• Respiratory rate is typically reduced and may gradually deteriorate to apnea

Pathophysiology

Biot’s respirations reflect disruption of medullary respiratory centers, frequently due to:

• Increased intracranial pressure (ICP)

• Brain stem compression (e.g., secondary to mass effect, herniation, or hemorrhage)

• Neurologic insults such as traumatic brain injury, central nervous system infections, or stroke

Emergency management

• Continuous observation is essential to distinguish Biot’s respirations from Cheyne-Stokes or other abnormal patterns.

• Immediate airway assessment and preparation for endotracheal intubation and mechanical ventilation.

• Monitor for signs of elevated ICP, including Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations).

• Position the patient with the head of the bed elevated to 30 degrees to promote venous drainage.

• Urgently initiate neuroimaging (CT or MRI) to identify the underlying cause.

• Involve neurosurgical and critical care teams early for definitive management.

Monitoring and supportive care

• Frequent monitoring of vital signs, oxygen saturation, and neurologic status

• Initiate measures to optimize cerebral perfusion

• Prepare for emergency decompressive intervention where indicated

Prognosis

• Biot’s respirations are typically indicative of severe and progressing neurologic injury

• Often precede respiratory arrest and neurologic demise

• Require urgent recognition and aggressive intervention

Family communication

Given the grave implications, it is critical to:

• Provide clear and compassionate communication with the patient’s family

• Offer emotional support

• Involve palliative care teams when appropriate

Pediatric considerations

• Biot’s respirations are rarely observed in pediatric populations

• When present, they signify similar underlying critical neurologic pathology

References

1. Schefold JC, Storm C, Krüger A, Ploner CJ, Hasper D. The Glasgow Coma Score is a predictor of good outcome in cardiac arrest patients treated with therapeutic hypothermia. Resuscitation. 2009;80(6):658–661.

2. Wijdicks EF. The bare essentials: Coma. Pract Neurol. 2010;10(1):51–60.