A Dangerous Myth: Does Speaking Imply Breathing?

Authored by acpjournals.org and submitted by littleike0

The belief that a person's ability to speak precludes the possibility of suffocation is false and can have fatal consequences. This commentary reviews basic respiratory physiology and highlights the clinician's role in educating the public against relying on speech as a sign of adequate respiration, especially when this misconception is used to propagate injustice or violence.

On 25 May 2020, George Floyd pleaded at least 16 times, “I can't breathe.” One officer in attendance nonetheless told bystanders, “He's talking. He's fine” (1, 2). Mayor Hal Marx of Petal, Mississippi, posted on Twitter the following day, “If you can say you can't breathe, you're breathing.” Similar arguments were put forth by New York Representative Peter King and police officials in the wake of Eric Garner's death in 2014 (3, 4). The belief that a person's ability to speak precludes the possibility of suffocation is not true and can have fatal consequences. Although the medical community may suspect that vocalization does not guarantee adequate respiration, they may not be sufficiently familiar with the relevant physiology to allow them to speak with authority. Here, we review basic respiratory physiology and highlight our role as clinicians and scientists in educating the public against relying on speech as a sign of adequate respiration—especially when this medical misconception is used to propagate injustice or violence.

The volume of an ordinary breath is approximately 400 to 600 mL. When each breath is inhaled, air first fills the upper airway, trachea, and bronchi; speech is generated here, but no gas exchange takes place in this anatomical dead space. Only air that exceeds the volume of this dead space is conducted to the alveoli for gas exchange. Normal speech only requires approximately 50 mL of gas per syllable—thus, stating “I can't breathe” would require 150 mL of gas (5). Anatomical dead space is typically one third the volume of an ordinary breath. George Floyd could have uttered those syllables repeatedly with small breaths that filled only the trachea and bronchi but brought no air to the alveoli, where actual gas exchange happens.

Phonation can occur with exhalation alone in the complete absence of inhalation by using the expiratory reserve volume that remains after a normal tidal breath is exhaled. In contrast, adequate gas exchange to support life requires inhalation, as well. A 70-kg adult requires 4 to 5 L of air per minute (at rest) to reach the alveoli, where oxygen and carbon dioxide are exchanged with the blood; light muscular activity requires double that, and a person in extremis may require more than 100 L of air per minute (6). If less air reaches the alveoli, there may be devastating cardiopulmonary consequences, including death.

The origin of the pernicious myth that speaking signals adequate breathing is unclear but may be an extrapolation from first aid training for choking. Multiple training sources cite the inability to talk as a sign of choking along with other late signs of respiratory compromise, including dusky skin or loss of consciousness (7). It is true that if you cannot move any air you cannot speak. However, the reverse is not true: You can move enough air to produce sound but not be able to breathe enough to sustain the gas exchange needed to prevent organ damage from hypoxemia. It is therefore not surprising that such a person as George Floyd may have been able to both generate the sentence “I can't breathe” and still experience severe air hunger (that is, dyspnea) and decompensate into a state of respiratory failure.

This apparent paradox is also consonant with our experiences as pulmonary and critical care clinicians. We all have taken medical histories and even discussed intubation with patients who had rapidly increasing carbon dioxide levels or decreasing oxygen levels and were clearly in respiratory failure. A colleague recalled her child having the ability to scream, “I can't breathe,” before losing consciousness from respiratory failure during an asthma exacerbation. As care providers, we are trained to prioritize addressing impairments to breathing and circulation above all else. Doing so includes recognizing earlier signs of respiratory failure, such as an increased respiratory rate, tripoding, or using accessory muscles to breathe. Waiting until a person loses the ability to speak may be too late to prevent catastrophic cardiopulmonary collapse.

Air hunger is the most uncomfortable and emotionally distressing quality of dyspnea. It directly activates the insular cortex, a primal sensory area of the brain that responds to such basic survival threats as pain, hunger, and thirst (8). Data from studies of war and torture victims show that the sensation of suffocation is the single strongest predictor of posttraumatic stress disorder and can cause more persistent psychological damage than mock execution with a pistol (9). This finding suggests that clinicians have a fundamental responsibility to serve as advocates for persons who report respiratory distress.

The use of incorrect physiologic statements to justify the force leading to the deaths of Eric Garner and George Floyd is unacceptable. According to our oath as clinicians, it is our responsibility to the public to aggressively correct such misconceptions to prevent further deaths. However, as human beings, we emphasize that it does not take medical training to inherently understand the profound danger and inhumanity behind forcibly inducing respiratory distress in another person. The persistent use of malignant platitudes in the face of another person's suffering is disturbing. At best, it represents the thoughtless use of heuristic shortcuts; at worst, it indicates deep gaps in empathy, toxic cognitive biases, or malicious intent. We hope that everyone will join us in advocating that all persons who describe respiratory distress receive immediate, serious attention and treatment.

References 1. Hill E, Tiefenthäler A, Triebert C, et al. How George Floyd was killed in police custody. The New York Times. 31 May 2020. Accessed at Google Scholar How George Floyd was killed in police custody. The New York Times. 31 May 2020. Accessed at www.nytimes.com/2020/05/31/us/george-floyd-investigation.html on 2 June 2020.

2. Culver J. What we know about the death of George Floyd: 4 Minneapolis police officers fired after ‘horrifying' video hits social media. USA Today. Updated 27 May 2020. Accessed at Google Scholar What we know about the death of George Floyd: 4 Minneapolis police officers fired after ‘horrifying' video hits social media. USA Today. Updated 27 May 2020. Accessed at www.usatoday.com/story/news/nation/2020/05/26/george-floyd-minneapolis-police-officers-fired-after-public-backlash/5263193002 on 2 June 2020.

3. CBS Interactive. NYPD chokehold victim Eric Garner complicit in own death, union says. 5 December 2014. Accessed at Google Scholar NYPD chokehold victim Eric Garner complicit in own death, union says. 5 December 2014. Accessed at www.cbsnews.com/news/nypd-chokehold-victim-eric-garner-complicit-in-own-death-union-says on 2 June 2020.

4. Mccalmont L. Rep. King: health issues led to death. Politico. 4 December 2014. Accessed at Google Scholar Rep. King: health issues led to death. Politico. 4 December 2014. Accessed at www.politico.com/story/2014/12/peter-king-eric-garner-reaction-113319.html on 2 June 2020.

5. Hoit JD, Lohmeier HL. Influence of continuous speaking on ventilation. J Speech Lang Hear Res. 2000;43:1240-1251. [PMID: 11063244] Google Scholar Influence of continuous speaking on ventilation. J Speech Lang Hear Res. 2000;43:1240-1251. [PMID: 11063244]

6. Castro RRT, Lima SP, Sales ARK, et al. Minute-ventilation variability during cardiopulmonary exercise test is higher in sedentary men than in athletes. Arq Bras Cardiol. 2017;109:185-190. [PMID: 28977060] doi:10.5935/abc.20170104 Google Scholar Minute-ventilation variability during cardiopulmonary exercise test is higher in sedentary men than in athletes. Arq Bras Cardiol. 2017;109:185-190. [PMID: 28977060] doi:10.5935/abc.20170104

7. American Red Cross. Conscious choking. 2011. Accessed at Google Scholar Conscious choking. 2011. Accessed at www.redcross.org/content/dam/redcross/atg/PDF_s/ConsciousChokingPoster_EN.pdf on 2 June 2020.

8. Banzett RB, Mulnier HE, Murphy K, et al. Breathlessness in humans activates insular cortex. Neuroreport. 2000;11:2117-2120. [PMID: 10923655] Google Scholar Breathlessness in humans activates insular cortex. Neuroreport. 2000;11:2117-2120. [PMID: 10923655]

9. Basoglu M. Waterboarding is severe torture: research findings. Mass Trauma, Mental Health & Human Rights: Metin Basoglu's Blog on War, Torture, and Natural Disasters. 25 December 2012. Accessed at Google Scholar Waterboarding is severe torture: research findings. Mass Trauma, Mental Health & Human Rights: Metin Basoglu's Blog on War, Torture, and Natural Disasters. 25 December 2012. Accessed at https://metinbasoglu.wordpress.com/2012/12/25/waterboarding-is-severe-torture-research-findings on 3 June 2020.

Boggfog on July 1st, 2020 at 18:53 UTC »

The whole myth got mixed in with general health classes and first aid classes telling everyone a choking person can't speak.

This is because there is literally an obstruction preventing air flow. You need air flow to speak.

So they automatically assume this is the same for every instance that involves "not being able to breathe".

Furthermore people who can't breathe aren't saying they literally can't breathe completely, they are saying they can't breathe enough. But no one says that in a panic.

So technically if you absolutely 100% can't breathe, like there is no oxygen getting out, then you can't speak. But most cases, other than choking, you're able to exhale in some capacity but you can't inhale enough to function.

When people say they can't breathe they mean they can't breathe very well. But no one will take it seriously if they say that. Hell, no one takes it seriously when they say they can't breathe.

the_real_hamm on July 1st, 2020 at 16:31 UTC »

anyone with asthma can tell you there's a huge difference between "breathing" and "breathing enough"

The_God_of_Abraham on July 1st, 2020 at 15:56 UTC »

They're really torturing the explanation here for what boils down to a single sentence: he was breathing, but not breathing enough.

It's not a binary choice between zero gas exchange and 100% exchange. If your heart beats once per minute, it's still beating, but you're still going to die. You can breathe enough to talk without breathing enough to live.