Types of Breathing for Nurses. Self Learn Series

This article is written for Nurses, by a Lecturer in Health Sciences. It describes the different types of respirations nurses see frequently in the Hospital situations. Respirations indicate the severity of illness and are often helpful in assessing the patients overall condition. This article will be useful for care givers and medical students as well. The diagrammatic representations are copyrighted materials of this author.

In this article the following are discussed and explained – Iron lungs, normal respiration, Bradypnea, Tachypnea, Kussmaul’s respirations, Biot’s respirations, Cheyne-stokes Respirations, apnea and respiratory arrest.

The ordinary word for respiration is breathing. Respiration is the movement of air from the exterior of the patient to the interior. Strictly speaking, this is called external respiration. Internal respiration is the metabolic process at cell level, equated with (combustion) because during this process oxygen is combined with carbohydrates to produce energy. Heat is a by-product of metabolism. During metabolism, energy is created for use by muscles for functions of life.

For optimal external respiration to occur, the patient must be placed in the optimal position for him/her. Patient positions are discussed in another article. The hyperlink is attached. Shergill , diagrams of the different positions are also available at that site.

Normal inspiration occurs because muscle activity, maily contraction, changes the volume of the intrathoracic cavity. When the volume increased, the pressure is decreased. The decreased pressure on the interior forces the air from the exterior to enter the lungs until the two pressures become roughly equal. At this point the stretch receptors stop the lung from expanding any further, in fact, the intercostal muscles relax. By recoil the pressure on the interior increses and expel air to the exterior. Normal tidal volumes and other respiratory parameters are found here. Iron lungs worked be decreasing the pressure on the outside, thereby lifting the rib cage to decrease the intra thoracid pressure.

Picture 1. Patient inside iron lungs for external respiration (victim of polio).
Iron lungs are now redundant. They have been replaced by high tech ventilators.

In the hospital environment, Nurses are the eyes and ears of the treatment team because they are with the patient all the time and usually know the patient best. As the patients condition changes so will his respiration. A brief description of the different types of respiration is given below. The normal respiratory rate is 12 to 18 breaths per minute. During each breath cycle the air moves in and out of the lungs quietly. The rib case rises and falls. There will also be some movement of the diaphragm, and abdominal region.

1. Normal Respiration . Respiratory rate depends upon age and condition of patient. Infants have very high respiratory rates. In Adults the respiratory rate is between 12 and 20 breaths per minute. In silent breathing the rise and fall is about the same. Small variations occur. In natural breathing, sighs occur naturally. A sigh is a larger than usual breath. In this type of breathing, there is a complete absence adventitious of sounds. The trained individual will be able to hear normal air enty and exit from the lungs. Diagramatic representation of rate and amplitude of breathing are shown in diagram numbered 1 (below).

Diagram 1. Graphic Representation of Normal Respirations / minute.

2. Bradypnea . This is a slow repiratory rate which is seen in the post anaesthetic or sedated patient. If blood gases are normal, the nurse will need to keep a close eye on the patient. If oxygen saturation and blood gases are compromised then the patient may need to be given naloxone or some other respiratory stimulant. Bradypnea is also seen in patients who have taken overdoses of barbiturates and/or hypnotics. Bradypnea with a respiratory rate of more than ten breaths may correct itself as the patient recovers from the anaesthetic gases. Sometimes, in bradypnea, the patient compensates by increasing the tidal volume thereby the blood gases and oxygen saturation remain stable. Diagramatic representation of bradypnea is shown in diagram numbered 2 (below).

Diagram 2. Graphic Representation of Bradypnea. Respiratory rate is 8b/min.

3. Tachypnea . Tachypnea means elevated respiratory rate. In some situations, this might be usual, for example when climbing a flight of stairs. In disease it is indicative of problems with oxygenation. It occurs when the patient is breathing really hard to compensate for the higher than usual PCO2. When the patient is tachypneic it is imporant to sit him up in bed. For nursing positions, please see: this article.

A diagramatic representation is shown in diagram 3 (below). In tachypnea the tidal volume is decreased, the minute volume may be the same because the respiratory rate is increased. Decreased tidal volume will have bad consequences for the patient because a lot of energy is being spent on moving dead air space which does not help oxygenate the interior of lungs where gas exchange takes place.

Diagram 3. Graphic Representation of Tachypnea. Respiratory rate is 28 b/min.

4. Kussmauls Respirations . This type of respirations are seen in very ill patients. It is a type respiration characterized by deeper noisy,and higher than normal respiratory rates. E ach breath is almost like a deep sigh but as already stated the rate is higher than usual. In these patients blood gases will be deranged because of a primary disorder for example diabetic ketoacidosis. Diagramatic representation is shown in diagram 4 (below).

Their hyperventilation helps get rid of ketones. This respiration was first described by Adolf Kussmaul, a German Physician.

Diagram 4. Graphic Representation of Kussmaul Respirations at 18 b / minute.

5. Biot’s Respirations . These respirations are characteristically a brupt and irregular. They alternate with periods of apnea with periods of breathing that are consistent in rate and depth, often the result of increased intracranial pressure. These are shown, in diagrammatic form below in diagram 5 (below).

Diagram 5. Graphic Representation of Biot’s Respirations. Rate is variable. Note the varialbe amplitued and apnea.

Maintainence and management of respiratory tract is discussed in my previous publication. Please see the attached hyperlink. Respiratory Tract Infections

6.Cheyne-stokes Respirations (breathing) is a type of breathing which starts of with small shallow respirations, gradually increase in frequency and amplitude and then decrease into a periond of apnea. The whole cycle may take upto two minutes. If you are the nurse standing by the bedside the period of apnoea may be frightening long. If your patient is hooked upto a pulase oxymeter, you will notice that his/her oxygen saturation does not drop. If oxygen saturation drops to below 95 % the physician should be notified.

Diagram 6 (above). Cheyne-Stokes Respiration. (Author of Diagram: Sarjeet S. Gill).

7. Apnea. Apnea is the cessation of breathing. There are no respirations during this period. During sleep apnea the patient stops breathing. This may be the result of upper air way obstruction. Some patients are placed on ventilators, at night, when at home, for this problem. Apnea will result in desaturation and constitutes a medical emergency. CPR must be started by the first person on the secene.

Diagram 7. Diagramatic representation of two breaths of different amplitues followed by apnea. (copyright of Diagram: Sarjeet S. Gill).

Dyspnoea means “difficult breathing”. Patients with advanced diseases like COPD and heart failure will display chronic dyspnoea. Shortness of breath will not be relieved, even at rest, in the chronically ill. Opioids and benzodiazepines may used with anxious patients. The respiratory rate can vary from 24 b/min to 50b/min. In these situations the work of breathing is substantially increased and the treating physician has to consider mechanical ventilation, if the condition is reversible.

Non-medical intervention is very important as the patient needs to learn to use his/her breathing optimally and to save each breath for those things that are most important. These interventions have been discussed before and can be found here.

Students are reminded that our subject matter is external respirations only. It is different from cell respiration which is given below to point out that the two processes are significantly different.

Aerobic Cell Respiration (internal respiration) is more efficient and more complicated than anaerobic respiration. Aerobic respiration uses oxygen and glucose to produce carbon dioxide, water, and ATP(energy). More precisely, this process involves six oxygen molecules for every sugar molecule:

6O 2 + C 6 H 12 O 6 = 6CO 2 + 6H 2 O + ATP energy.

Since, I started this topic with iron lungs I feel it appropriate it to end it with iron lungs. Currently, iron lungs are confined to hospital and nursing museums. See the picture below to get a feel.

Picture 2: ?“Good Old” Days of Polio and Iron Lungs Ward.

None of the information is to be used for diagnostic and/or treatment purposes. Only duly qualified physicians are authorized to diagnose and treat patients.