Rocuronium-induced respiratory paralysis refractory to sugammadex in Charcot-Marie-Tooth disease.

PURPOSE: Prolonged postoperative neuromuscular respiratory paralysis after administration of a nondepolarizing neuromuscular blocking agent is a serious concern during anesthetic management of patients with Charcot-Marie-Tooth disease (CMTD). Some recent reports have described rocuronium use without respiratory paralysis in CMTD patients when sugammadex was used for its reversal. We report a case in which an induction dose of rocuronium caused a prolonged respiratory paralysis in a patient with undiagnosed type 1A CMTD (CMT1A). CLINICAL FEATURES: A 63-yr-old-male with an American Society of Anesthesiologists Physical Status score of III underwent a left hip arthroplasty under general anesthesia for osteoarthritis. Preoperative pulmonary function testing indicated a restrictive impairment. Anesthesia was induced with fentanyl, remifentanil, propofol, and 0.73 mg·kg-1 of rocuronium. The train-of-four (TOF) count was 0 for the 273-min duration of surgery. After repeated doses of sugammadex failed to recover the TOF count and spontaneous respirations, a total of 1,200 mg (17.3 mg·kg-1) of sugammadex, which was assumed to be a sufficient amount for capturing the residual rocuronium, was administered. Although the patient expressed that he was awake via eye blinking, he could not breathe. Thus, he was placed on mechanical ventilation for 18 hr after surgery. A postoperative neurology consultation revealed a delayed nerve conduction velocity of 20 m·sec-1 and a mutated duplication of the PMP22 gene; a diagnosis of CMT1A was made. CONCLUSIONS: Our case shows that rocuronium can cause a prolonged neuromuscular respiratory paralysis refractory to sugammadex in patients with CMT1A and impaired respiratory function. Our case may also indicate that restrictive pulmonary impairment and low nerve conduction velocity of 20 m·sec-1 are predictive factors that cause prolonged neuromuscular respiratory paralysis refractory to sugammadex in CMT1A.

RéSUMé: OBJECTIF: La paralysie respiratoire neuromusculaire postopératoire prolongée après l'administration d'un bloqueur neuromusculaire non dépolarisant est une préoccupation sérieuse lors de la prise en charge anesthésique des patients atteints de la maladie de Charcot-Marie-Tooth (CMT). Certains comptes rendus récents ont décrit l'utilisation de rocuronium sans paralysie respiratoire chez les patients atteints de CMT lorsque le sugammadex était utilisé pour le neutraliser. Nous rapportons un cas dans lequel une dose d'induction de rocuronium a provoqué une paralysie respiratoire prolongée chez un patient atteint de CMT de type 1A (CMT1A) non diagnostiquée. CARACTéRISTIQUES CLINIQUES: Un homme de 63 ans avec un score de statut physique III selon la classification de l'American Society of Anesthesiologists a bénéficié d'une arthroplastie de la hanche gauche sous anesthésie générale pour son ostéo-arthrite. Les tests préopératoires de la fonction pulmonaire ont indiqué un syndrome restrictif. L'anesthésie a été induite avec du fentanyl, du rémifentanil, du propofol et 0,73 mg·kg-1 de rocuronium. Le décompte du train-de-quatre (TdQ) était de 0 pour toute la durée de la chirurgie, soit 273 minutes. Après l'échec de doses répétées de sugammadex qui n'ont pas réussi à rétablir un TdQ normal ni la respiration spontanée, un total de 1200 mg (17,3 mg·kg-1) de sugammadex (une quantité qu'on a présumé suffisante pour neutraliser le rocuronium résiduel) a été administré. Bien que le patient ait exprimé qu'il était éveillé en clignant des yeux, il ne pouvait pas respirer. Il a donc été placé sous ventilation mécanique pendant 18 heures après l'opération. Une consultation postopératoire en neurologie a révélé une vitesse de conduction nerveuse retardée de 20 m·sec-1 et une duplication mutée du gène PMP22; un diagnostic de CMT1A a été posé. CONCLUSIONS: Notre cas montre que le rocuronium peut provoquer une paralysie respiratoire neuromusculaire prolongée réfractaire au sugammadex chez les patients atteints de CMT1A et d'une altération de la fonction respiratoire. Notre cas pourrait également indiquer qu'un syndrome restrictif pulmonaire et une faible vitesse de conduction nerveuse de 20 m·sec-1 constituent des facteurs prédictifs provoquant une paralysie respiratoire neuromusculaire prolongée réfractaire au sugammadex dans les cas de CMT1A.

Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults? Review of the literature and results of a national survey.

Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field. To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases. Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach. We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.

Functional outcomes in unstable complete subaxial cervical spinal injuries with respiratory paralysis and/or hemodynamic instability.

INTRODUCTION: Subaxial cervical spine injuries (SCSI) can lead to disastrous consequences such as quadriplegia, with/without respiratory paralysis (RP) and hemodynamic instability (HDI). Till date, there is no literature available for reporting outcomes of SCSI patients specifically pertaining to those presenting with RP/HDI and ours is the first study to document the same. METHODS: Retrospective 6-year study from a tertiary trauma centre database including patients >/= 18 years of operated SCSI. Only patients with ASIA A grade with admission RP/HDI and unstable injuries (fractures, subluxations) were included. Patients with ASIA grade B and above, patients with non-osseous injuries (such as disc herniation, central cord syndrome etc.) were excluded. RESULTS: 24 cases were analysed. C5 and C6 levels were the commonest. Vertebral listhesis/subluxation was the predominant radiological finding. The mean age was 47.4 years (22-79 years) and all, except one were males. Fall from height and road traffic accident (RTA) were the most common mechanisms of injury. The most common surgery was anterior discectomy and fusion followed by corpectomy. The overall mortality rate was 22/24 (92)%. Cord edema and hemorrhage had significant association with survival. None of the grade A survivors with HDI/RP showed improvement. The mean FU duration was 18.5 months (range, 16.5-20.5 months). CONCLUSIONS: Subaxial ASIA A cervical spine injuries with pre-operative RP/HDI is an indicator for non-improvement. This is the first study documenting outcome in such patients. The mortality rate in these patients is very high and is an extremely poor prognostic factor for recovery. Hence, surgery in such patients need to be decided judiciously, especially in developing countries that has a significant financial impact on the family members.

Efficacy and Safety Analysis of Botox Application and Iatrogenic Botulism: Panacea or Peril?

Clostridium botulinum toxin-A (BoNT-A) creates temporary paralysis in the muscles by acting on the muscle-nerve junction. It is injected into the mimic muscles when a decrease in the movements of the mimic muscles is desired. Despite many favorable applications, the use of BoNT-A is not without drawbacks. Although there is no expected serious side effect on health in BoNT-A treatments, various problems can be encountered in patients treated for aesthetic purposes. Botulism is a rare but potentially life-threatening syndrome, which is caused by the toxin produced by the bacterium Clostridium botulinum, which acts on the nervous system, vegetative forms of C. botulinum can only survive in anaerobic conditions, while spore forms are common in nature and can withstand harsh conditions. Botulism can stem from bacterial spores which release toxin in the body; in the form of enteric botulism, and wound botulism. The cases that develop 'iatrogenic botulism' after such procedures are usually those receiving high-dose toxin for therapeutic purposes. The treatment of botulism mainly consists of anti-toxin therapy and, if necessary, intensive care to prevent organ failures, including respiratory support. This article aims to cover all these issues related to botulism and other adverse outcomes related to BoNT-A injection in light of the most recent literature.

Vocal Impact in Patients With Unilateral Diaphragmatic Paralysis.

OBJECTIVES: This study aimed to investigate the possible vocal impact confirmed by diagnostic tests, the degree of perception of possible vocal impairment by patients with Unilateral Diaphragmatic paralysis (UDP) and its correlation with ventilatory weakness. METHODS: The researchers conducted an analytical, observational and case-control study with 70 individuals, including 35 UDP patients and 35 healthy patients in a control group, who underwent the following assessments: 1) Self-assessment of voice handicap (VHI-10); 2) Self-Assessment of Quality of Life (SF-36); 3) Self-Assessment of Dyspnea (MRC); 4) Objective vocal measures (Maximum Phonation Time (MPT) in /a/, /s/, /z/ and glottal-to-noise excitation ratio); 5) Functional respiratory pressures (Spirometry and maximum ventilatory pressures); 6) General degree of dysphonia - G on the GRBAS Scale. The sex, age and body mass index (BMI) of the individuals were the variables used to match the sample of this study. RESULTS: When compared with controls, patients with UDP had a restrictive functional pattern and inspiratory weakness, with symptoms of dyspnea and worsening quality of life. When associated with a possible vocal impact, these patients had voice handicap and decreased MPT values for all phonemes, especially /a/. There was also a correlation between vocal performance and inspiratory weakness. However, it should be noted that, despite having vocal impairment, many patients did not report the perception of this fact, somehow neglecting such impairment. CONCLUSIONS: In addition to the expected weakness of the ventilatory muscles, patients with UDP had clinically verified vocal impact, and those who had greater inspiratory weakness also had greater voice impairment. Finally, it is relevant that not all patients perceived such vocal impact, which showed a very reduced perception of this impairment in patients with UDP.

Suspected intermediate syndrome in a dog after organophosphate poisoning.

OBJECTIVE: To discuss the clinical presentation and successful treatment of a suspected case of intermediate syndrome due to organophosphate (OP) poisoning in a dog. CASE SUMMARY: Two dogs presented with acute cholinergic signs after ingesting an OP insecticide containing 50% acephate. Clinical signs consistent with acute cholinergic crisis resolved in both dogs within 24 hours postingestion. One dog developed an onset of neurological signs consistent with intermediate syndrome approximately 24 hours postingestion. This patient's clinical signs resolved with the use of pralidoxime chloride. NEW OR UNIQUE INFORMATION PROVIDED: OP poisoning most commonly presents as an acute cholinergic crisis, with rare instances of animals developing intermediate syndrome. Few reports of successful treatment and recovery from intermediate syndrome exist in the veterinary literature, particularly with instances in which 2 dogs within the same exposure setting were treated for acute cholinergic signs and only 1 progressed to an intermediate syndrome. This report also highlights the importance of early intervention with pralidoxime chloride prior to the onset of aging.

Validation of Point-of-Care ultrasound in the diagnosis of a diaphragmatic hernia.

Point-of-care ultrasound (POCUS) is a sensitive, specific tool for early diagnosis of diaphragm pathology in critically ill patients. We report the case of a patient with a history of iatrogenic diaphragmatic hernia who was admitted to the Resuscitation Unit after an emergency exploratory laparotomy. As the diagnosis of diaphragmatic hernia had already been confirmed, we determined the POCUS features that establish the diagnosis of diaphragmatic hernia: (1) normal bilateral diaphragmatic shortening fraction; (2) decreased diaphragmatic excursion; and (3) cephalic position of the diaphragmatic dome (4) greater in supine than in sitting position. We also outline a systematic ultrasound examination of the diaphragm and a POCUS-based differential classification of diaphragmatic dysfunction based on the functional integrity of the peripheral muscle and central diaphragmatic tendon in critically ill patients.

Resolution of tracheostomy complications by decanulation and conversion to noninvasive management for a patient with high-level tetraplegia.

OBJECTIVES: To report conversion from tracheostomy (TIV) to noninvasive intermittent positive pressure ventilation (NIV) for a continuously ventilator-dependent patient with high-level spinal cord injury (SCI) with no measurable vital capacity (VC = 0 mL) to resolve tracheostomy-associated complications. METHODS: A case report of a 38-year-old female in a chronic care facility in Japan with a 10-year history of ventilator-dependent tetraplegia (C1 ASIA-A) presented for increasing difficulty vocalizing. She had been using a fenestrated cuffed tracheostomy tube to produce speech with the cuff deflated. Speech was increasingly hypophonic, because of tracheostoma enlargement, tube migration, and tracheal granulation. RESULTS: The NIV was provided via nasal and oral interfaces, the ostomy was surgically closed, and vocalization resumed. Airway secretions were expulsed using manually assisted coughing. The patient returned to the community. CONCLUSION: Conversion to NIV should be considered for ventilator-dependent patients with SCI who have adequate bulbar-innervated muscle function to permit effective speech and assisted coughing.

Case Report: Respiratory paralysis associated with polymyxin B therapy.

Polymyxin B (PMB) and colistin are bactericidal polypeptide antibiotics discovered in 1947 and 1949 for the treatment of gram-negative bacterial infections. Polymyxin was used clinically in the 1950s, but it was gradually replaced by other antibiotics in the 1980s because of its high nephrotoxicity and neurotoxicity. In recent years, the increase of multidrug-resistant negative bacteria has led to the resurgence of polymyxin use. However, its side effects are not clear. Respiratory paralysis caused by PMB-related neuromuscular blockade is a rare but potentially fatal effect. We report a case of respiratory paralysis probably caused by polymyxin B infusion.

Delayed Neurological Manifestation in Krait Bites Despite Anti-snake Venom Therapy.

A severe medical emergency that poses a life-threatening risk is envenomation from a snake bite. Among the several snake families, krait bites are known to result in neurological symptoms, including ptosis, headache, and sweating. A 12-year-old adolescent boy who had been bitten by a krait appeared in this instance. The patient showed neurological symptoms after receiving anti-snake venom (ASV). He had three rounds of ASV and made a full recovery. To the best of our knowledge, there have not yet been any reports of this kind of delayed neurological signs after a krait bite, despite getting ASV in the adolescent population.

Shrinking Lung Syndrome: A Case Report.

Shrinking Lung Syndrome (SLS) is an uncommon complication of systemic lupus erythematosus (SLE). SLS is a diagnosis of exclusion with features of dyspnea ruled out by other causes using imaging and diagnostic studies, pleuritic chest pain, and elevated diaphragm. Currently, there are many theories of the etiology; however, there is no clear pathogenesis, conclusive treatment, and preventative measures. We report a case of a 41-year-old woman with SLE admitted for pleuritic chest pain with unclear cause of shortness of breath. After CTA chest study, laboratory, chest x-ray, and pulmonary function test we were able to appropriately diagnose her with SLS and treat her with steroids as per limited current research guidelines.

Marked Respiratory Failure in an Ambulant Patient with Immune-mediated Necrotizing Myopathy and Anti-Kv1.4 and Anti-titin Antibodies.

We herein report a case of seronegative immune-mediated necrotizing myopathy (IMNM) concurrent with anti-Kv1.4 and anti-titin antibodies. A 72-year-old Japanese woman presented with a 29-year history of fluctuating high serum creatine kinase (CK) levels followed by intermittent ptosis and respiratory muscle weakness. This case highlights the fact that marked respiratory muscle weakness requiring intubation can be seen in an ambulant patient with IMNM. Marked respiratory muscle weakness, rhabdomyolysis-like acute elevation of CK levels, and anti-striational muscle antibodies may be a characteristic constellation of findings in a distinct subgroup of patients with inflammatory myopathy with myasthenia gravis or similar symptoms.

Bilateral diaphragmatic paralysis and Lyme neuroborreliosis. Ten years of follow-up.

Borrelia burgdorferi infection (Lyme disease) is one of the few identifiable causes of neuralgic amyotrophy. Bilateral diaphragmatic paralysis is considered rare in borreliosis, and the pattern of long-term recovery of diaphragm function is also uncertain. Transdiaphragmatic pressure is the gold standard for diagnosis of bilateral diaphragmatic paralysis, a study that has been reported on few occasions. We present a case of neuralgic amyotrophy associated with Borrelia infection and bilateral diaphragmatic paralysis that provides a detailed follow-up of the spirometric evolution, of the maximum static pressures in the mouth and of transdiaphragmatic pressure from the onset of symptoms and the long term. This case allows us to know one of the possible evolutionary profiles of diaphragmatic dysfunction in neuralgic amyotrophy due to borreliosis.

La infección por Borrelia burgdorferi (enfermedad de Lyme) es una de las pocas causas identificables de amiotrofia neurálgica. La parálisis diafragmática bilateral es considerada rara en la borreliosis y el patrón de recuperación a largo plazo de la función del diafragma también es incierto. La presión transdiafragmática es el patrón de oro para el diagnóstico de parálisis diafragmática bilateral, un estudio que ha sido informado en pocas ocasiones. Se presenta un caso de amiotrofia neurálgica asociado a infección por Borrelia y parálisis diafragmática bilateral, que aporta un seguimiento detallado de la evolución espirométrica, de las presiones estáticas máximas en la boca y de la presión transdiafragmática desde el inicio de los síntomas y a largo plazo. Este caso permite conocer uno de los posibles perfiles evolutivos de la disfunción diafragmática en la amiotrofia neurálgica por borreliosis.

[Bilateral diaphragmatic palsy due to Lyme neuroborreliosis]. / Une paralysie diaphragmatique bilatérale révélant une neuroborréliose de Lyme.

INTRODUCTION: Lyme disease is not uncommon and can sometimes progress to neurological complications. We report here an unusual case of bilateral diaphragmatic paralysis secondary to Lyme neuroborreliosis. CASE REPORT: A 79-year-old man was admitted to the intensive care unit for acute respiratory distress requiring intubation and the long-term use of nocturnal non-invasive ventilation. Three months beforehand he had been bitten by a tick and developed erythema migrans which was treated with Doxycycline for 10 days. This clinical presentation became complicated a few days later by the progressive onset of severe dyspnoea. At admission, chest radiography revealed bilateral elevation of the diaphragm. Pulmonary function tests revealed a severe restrictive disorder aggravated by decubitus. A diaphragmatic electromyogram showed bilateral axonal polyneuropathy of the phrenic nerves. IgG and IgM antibodies to Borrelia burgdorferi were detectable in serum and cerebrospinal fluid, leading to the diagnosis of Lyme disease. He was treated with intravenous ceftriaxone 2g per day for 21 days, leading to a substantial improvement in symptoms. CONCLUSION: In the presence of unilateral or bilateral diaphragmatic paralysis of undetermined aetiology, it seems relevant to perform Lyme serology in the blood and, in positive cases, to follow up with a lumbar puncture in order to detect intrathecal IgG synthesis.

Acute Neuromuscular Respiratory Weakness Due to Acute Inflammatory Demyelinating Polyneuropathy (AIDP): A Simulation Scenario for Neurology Providers.

Introduction: Acute neuromuscular respiratory failure is a source of morbidity and mortality in neurological diseases, including acute inflammatory demyelinating polyneuropathy (AIDP), also known as Guillain-Barré syndrome. It is important for health care providers to recognize this condition and provide early ventilatory support. In this simulation, learners must assess and treat a standardized patient with acute respiratory complications related to AIDP. Methods: This is a single-session simulation that can be run in a standard simulation center using a live standardized patient. The simulation scenario is followed by a facilitated debriefing session. Details about the simulation scenario, critical action checklist, environment preparation, actors/roles, and debriefing session are outlined. Results: A total of 14 neurology residents participated in this simulation. A postsimulation survey revealed that participants thought the simulation achieved its stated objectives, was useful, and would impact their future practice. Discussion: We designed this simulation to assess a learner's ability to identify acute neuromuscular respiratory weakness in a patient with AIDP and initiate treatment with ventilatory support. This simulation can easily be incorporated into an existing curriculum for neurology residents or for trainees in other specialties.

Falla en la extubación en el paciente con trauma raquimedular: parálisis diafragmática. Una entidad por considerar

La parálisis diafragmática es una entidad con epidemiologia no constatada, sin embargo, debe considerarse en el paciente con antecedente de trauma raquimedular asociado que presente signos tempranos de dificultad respiratoria, para de esta forma investigar y ofrecer manejos oportunos en esta condición clínica. Se presenta caso de varón de 65 años con debilidad diafragmática crónica por antecedente de herida por arma de fuego a nivel de la columna cervical.

Diaphragmatic paralysis is an entity with an unproven epidemiology. However, it should be considered in patients with a history of associated spinal cord trauma who present early signs of respiratory difficulty, to investigate and offer timely management to this clinical condition. We present the case of a 65-year-old man with chronic diaphragmatic weakness due to a history of gunshot wounds at the level of the cervical spine.

In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm.

Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Fontan Failure Secondary to Charcot-Marie-Tooth-Induced Phrenic Neuropathy.

Charcot-Marie-Tooth disease comprises a vast array of defects in myelin integrity that causes progressive peripheral sensorimotor neuropathy. It is the most prevalent inherited peripheral neuropathy, and it can affect the management of coexisting medical conditions. We report the case of a 25-year-old woman who had undergone successful Fontan surgery during childhood, but her Fontan circulation failed as a result of diaphragmatic paresis caused by Charcot-Marie-Tooth disease type 1A. This diagnosis precluded cardiac transplantation.

Control de la ventilación y regulación del estado ácido-base del pez al hombre / Control of ventilation and regulation of acid-base status from fish to man

RESUMEN Este artículo analiza ciertos aspectos evolutivos en el intercambio gaseoso, el desa rrollo pulmonar, la bomba respiratoria, el estado ácido-base y el control de la ventila ción en relación con un evento trascendente: el pasaje de la vida acuática a la terres tre. Su estudio puede permitir comprender ciertos aspectos con los que lidiamos en la práctica clínica: ¿Por qué las personas con debilidad muscular respiratoria extrema respiran como ranas (respiración frog)?, ¿Por qué los recién nacidos con dificultad respiratoria tienen aleteo nasal y quejido espiratorio?, ¿cómo es posible que los mús culos abdominales, típicamente espiratorios, asistan a la inspiración en casos de la parálisis diafragmática?, ¿por qué en la insuficiencia respiratoria el patrón respiratorio tiene menos variabilidad y se torna más rígido? y, por último, ¿es posible imaginar un pH neutro que no tenga el valor de 7,0, para qué sirve este conocimiento y como se deben interpretar los gases en hipotermia? La transición del agua a la tierra es una de las más importantes e inspiradoras de las grandes transiciones en la evolución de los vertebrados. Ante la sorprendente diversi dad de organismos vivos, es tentador imaginar una cantidad enorme de adaptaciones evolutivas para resolver los diferentes desafíos que cada especie tiene para la vida en la tierra. Hay desarrollos tempranos que comparten algunos factores cruciales y algunas de las redes genéticas regulatorias cercanas y lejanas están conservadas. Somos testigos de hallazgos clínicos que son el testimonio de especies que han vivido en épocas remotas y nos han legado su historia evolutiva.

ABSTRACT This article analyzes certain evolutionary aspects of gas exchange, lung development, the respiratory pump, the acid-base status and control of ventilation in relation to a significant event: the passing from aquatic to terrestrial life. By studying this, we can understand certain aspects that are present in the clinical practice: Why do people with extreme respiratory muscle weakness breathe as frogs? (frog breathing); why do newborns with breathing difficulties have nasal flaring and expiratory grunting?; how is it possible that abdominal muscles, which are typically expiratory, assist with inspira tion in cases of diaphragmatic paralysis?; why does the breathing pattern of respiratory failure has less variability and becomes more rigid? and, finally, is it possible to imagine a neutral pH that doesn't have the 7.0 value?; what's the use of this knowledge, and how should gases in hypothermia be interpreted? Water-to-land transition is one of the most important and inspiring major transitions of vertebrate evolution. Given the amazing diversity of living organisms, it is tempting to imagine an enormous amount of evolutionary adaptation processes to solve the different challenges of living on earth faced by each species. There are certain early development processes that share some crucial factors, and some of the close and distant gene regulatory networks are conserved. We are witnesses of clinical findings that serve as testimony of the species that lived in remote times and left us their evo lutionary history.