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Clinical Practice Keywords Respiratory rhythm/Vital signs/Patient deterioration Practical procedures This article has been Respiratory double-blind peer reviewed Respiratory rate 4: breathing rhythm and chest movement

changing respiratory rate (RR) pulmonary disease, the respiratory rhythm Author Iain Wheatley is nurse consultant measurement is cited as an and chest movement change. These in acute and respiratory care, Frimley early indicator of patient deteri- changes are compensatory mechanisms as Health Foundation Trust. Aoration (Dougherty and Lister, a direct result of a chemical imbalance; and 2015), but there are other respiratory signs the primary cause may be mechanical, met- Abstract Breathing rhythm and chest that can be observed in conjunction with it. abolic or neurological. The changes result movement provide key information on a In normal breathing a fairly steady rate, in an increase or decrease in RR, depth of patient’s condition. The fourth article in inspiratory volume and depth of chest breathing and pattern of breathing. this six-part series on respiratory rate movement are maintained, with equal Changes in rhythm and chest move- expands on the procedure to measure expansion and symmetry. In the resting ments are made through feedback mecha- respiratory rate outlined in part 3 and state normal breathing is relaxed, regu- nisms to the central respiratory control provides a guide to the assessment of lating the gas exchange in the lungs to centres of the brain. A range of receptors respiratory rhythm and chest movement. maintain homoeostasis and balance pH provide information that is interpreted in changes and metabolism. the higher respiratory centre, modulating Citation Wheatley I (2018) Respiratory When there is an increased demand on RR and chest movement (Feldman and Del rate 4: breathing rhythm and chest the respiratory system from an acute epi- Negro, 2006); these receptors are: movement. Nursing Times; 114: 9, 49-50. sode, such as a chest infection, or long-term l Peripheral chemoreceptors found in the

conditions, such as chronic obstructive carotid artery detect changes in PaO2 in

the blood as well as PaCO2 and pH; Fig 1. Chest and abdominal movement l Central chemoreceptors in the ventral medullary surface of the medulla oblongata in the brain detect pH changes; A. Normal l Mechanoreceptors are stretch receptors located in the smooth muscle of the main airways and parenchyma. They respond to excessive stretching of the lung during inspiration and send signals to the apneustic centre of the pons B. Paralyzed (located in the brain stem); the pons controls inspiration and expiration.

Respiratory rhythm and chest Source: Adapted from McCool and Tzelepis (2012) movement Normal Table 1. Breathing patterns In relaxed normal breathing the RR is 12-20 breaths per minute (bpm) (Royal Col- Pattern Condition Description lege of Physicians, 2017). Chest expansion on Eupnoea Normal breathing rate and pattern inspiration should be the same or similar on Tachypnoea Increased respiratory rate each breath. The chest wall is symmetrical, accessory (neck and shoulder) muscles are Bradypnoea Decreased respiratory rate not used, diaphragm muscles are func- Apnoea Absence of breathing tioning, and there is no paradoxical move- Hyperpnoea Increased depth and rate of breathing ment – the chest and abdomen move in the same direction on inspiration and expiration. Cheyne-Stokes Gradual increases and decreases in respirations with periods of apnoea Abnormal Biot’s Abnormal breathing pattern with groups/clusters of There are several reasons why respiratory rapid respiration of equal depth and regular apnoea rhythm and chest movement may change. periods Abnormality in respiratory rhythm may be Kussmaul’s Tachypnoea and hyperpnoea related to changes in the patient’s metabolic state; for example, a patient with diabetic Apneustic Prolonged inspiratory phase with a prolonged ketoacidosis may exhibit signs of rapid, deep expiratory phase

PETER LAMB PETER breaths. Such breathing (often called

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Clinical Practice This article is funded by an unrestricted Practical procedures educational grant from PMD Solutions

Table 2. position and observing the movement from Causes of abnormal respiratory rate the side gives the best view. Observation Respiratory changes Possible causes 3. Depth of chest movement – in normal Chest symmetry One side of the anterior ● Unilateral consolidation tidal breathing the inspiratory and expira- chest moves more with ● Pneumothorax tory movement is fairly constant. Monitor normal tidal breaths ● Pleural effusion for tachypnoea (>25bpm) or bradypnoea than the other ● Fractured ribs (flail chest) (<12bpm) and assess whether the tidal breath ● Blocked chest drain is very deep or shallow (RCP, 2017). ● Partial diaphragm paralysis ● Sputum plugging 4. Accessory muscle use – observe the Paradoxical chest Chest moves in opposite ● Neuromuscular disorder patient from the front and note whether and abdominal direction to the ● Spinal injury there is increased work of breathing at rest, movement abdomen during normal ● Diaphragmatic paralysis which includes the use of the sternocleido- tidal breathing mastoid (neck), scalene (shoulder), pectoral and abdominal muscles (Tulaimat and Rapid and Tachypnoea and deep ● Metabolic acidosis such as diabetic Trick, 2017). The patient may sit forward increased depth inspiratory breaths ketoacidosis (Kussmaul’s breathing) with their hands on their knees or resting of breathing or renal failure on a table to relieve respiratory muscles and ● Sepsis increase inspiratory capacity. ● After exercise Rapid and shallow Tachypnoea and shallow ● Chest pain 5. Rhythm – breathing rhythm is usually depth of inspiratory breath ● Abdominal pain constant and regular; a rhythm with breathing ● Fractured ribs (pain) abnormally long pauses between breaths ● Sleep-disordered breathing pattern or cessation of breaths and then rapid ● Cerebral lesion breathing is abnormal (Table 1). ● Shock ● Anxiety/stress Conclusion ● Medication It is important to observe RR and to Slow and Bradypnoea with deep ● Brainstem lesion, impending death examine the rhythm of breathing and increased depth tidal breath, for ● Damage to the pons (respiratory movement of the chest when conducting a of breathing example: centre in the brainstem that controls respiratory assessment. This observation ● Apneustic breathing breathing) can aid rapid diagnosis and treatment par- ● Cheyne-Stokes ● Congestive heart failure, neurological ticularly in patients who are acutely ill. NT respirations insult (after, for example, a stroke) ● Biot’s respiration ● Elevated intracranial pressure, for References Dougherty L, Lister S (2015) The Royal Marsden example, meningitis Manual of Clinical Nursing Procedures. Oxford: ● Sleep apnoea Wiley-Blackwell. Feldman JL, Del Negro CA (2006) Looking for Slow and shallow Bradypnoea with ● Neuromuscular disorders inspiration: new perspectives on respiratory rhythm. depth of shallow tidal breath ● Opioid toxicity Nature Reviews Neuroscience; 7: 3, 232-241. McCool FD, Tzelepis GE (2012) Dysfunction of the breathing ● Hypopnoea (a partial blockage of diaphragm. New England Journal of Medicine; 366: the airway resulting in airflow 10, 932-942. Royal College of Physicians (2017) National Early reduction of >50% for ≥10 seconds) Warning Score (NEWS) 2. Bit.ly/NEWS2RCP ● Hypothyroidism Tulaimat A, Trick WE (2017) DiapHRaGM: a mnemonic to describe the work of breathing in patients with respiratory faialure. PLoS One; 12: 7: e0179641. Kussmaul’s breathing) aims to reduce the RR. The key principles of chest observation Wheatley I (2018) Respiratory rate 3: how to take an accurate measurement. Nursing Times; 114: 7, 21-22. level of CO2 in the blood to maintain a normal are outlined below. It is important to have a pH and re-establish a homoeostatic state. clear view of the chest so the chest area Patients with chest pain may have rapid should be exposed. Protect the patient’s CLINICAL Respiratory rate series but shallow breaths because deep breaths dignity at all times by screening the bed. SERIES cause discomfort; in patients with rib frac- Part 1: Why measurement and recording tures adequate pain relief is paramount to 1. Chest symmetry – standing in front of are crucial Bit.ly/RespiratoryR1 restore a normal depth and rate of and facing the patient, observe whether Part 2: Anatomy and physiology of breathing breathing. Table 1 outlines common rhythm the movement of both sides of the anterior Bit.ly/RespiratoryR2 patterns, while Table 2 details key respira- chest is symmetrical. Part 3: How to take an accurate measurement tory changes and possible causes. Bit.lyRespiratoryR3 2. Chest and abdominal movement – the Part 4: Respiratory rhythms and chest The procedure chest and abdomen should move in the movement Observation of respiratory rhythm and same direction during a normal tidal breath Part 5: Respiratory rate and the deteriorating patient chest movement can be incorporated into (Fig 1) but it can be difficult to observe this. Part 6: Technology in respiratory assessment Wheatley’s (2018) procedure for assessing Positioning the patient in a semi-recumbent

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