Assessment of Respiratory Distress

Clinical Orientation

A nurse walks into a patient's room and immediately knows something is wrong. The patient is sitting bolt upright, gripping the side rails, using neck muscles to breathe, and can only speak in single words. SpO2 reads 86%. This chapter answers: How do you rapidly assess respiratory distress and recognize when compensation is about to fail?

The Respiratory Distress Assessment

Look — before you touch anything:

1. Position: Tripod position (leaning forward, arms braced) = severe distress. Inability to lie flat.
2. Facial expression: Wide-eyed, anxious, "air hunger" look.
3. Color: Cyanosis (lips, nail beds — late sign). Pallor.
4. Accessory muscle use: Sternocleidomastoid, scalenes, intercostal retractions, supraclavicular retractions, nasal flaring.
5. Respiratory pattern: Rate, depth, rhythm. Pursed-lip breathing (COPD — creates back-pressure to keep airways open). Paradoxical breathing (abdomen moves IN with inspiration — diaphragmatic fatigue/failure).
6. Ability to speak: Full sentences = mild. Phrases = moderate. Single words = severe. Cannot speak = critical.

Listen:

• Wheezes: Musical, continuous — narrowed airways (asthma, COPD). Expiratory > inspiratory.
• Crackles (rales): Discontinuous, bubbling/popping — fluid in alveoli (pneumonia, pulmonary edema, fibrosis).
• Rhonchi: Low-pitched, snoring — secretions in large airways. May clear with coughing.
• Stridor: High-pitched, inspiratory — upper airway obstruction (croup, epiglottitis, foreign body, angioedema). EMERGENCY.
• Absent/decreased breath sounds: No air moving — pneumothorax, severe asthma (silent chest), pleural effusion, complete obstruction.

Feel:

• Chest expansion: Symmetric? Decreased on one side (pneumothorax, effusion, consolidation).
• Tactile fremitus: Increased (consolidation), decreased (effusion, pneumothorax).
• Tracheal position: Midline? Deviated (tension pneumothorax pushes trachea AWAY from affected side).

Stages of Deterioration

1. Compensated: Increased RR, HR. Mild accessory muscle use. Anxious. Able to speak in sentences.
2. Decompensating: Significant accessory muscle use. Inability to complete sentences. Diaphoresis. SpO2 may be maintained. Rising PaCO2 (ominous).
3. Impending arrest: Decreasing RR (fatigue!). Altered mental status. Silent chest. Paradoxical breathing. Bradycardia (preterminal).

The most dangerous sign: A previously tachypneic, distressed patient whose respiratory rate is now "normalizing" — this may be fatigue and impending respiratory arrest, not improvement.

Nursing Priorities

1. Stay with the patient. Do not leave a patient in severe respiratory distress.
2. Call for help early. Respiratory failure is easier to prevent than to treat.
3. Position for optimal ventilation: Upright (High Fowler's). Tripod if tolerated. Do NOT force a distressed patient to lie flat.
4. Apply oxygen: Start high-flow if severe. Titrate to target SpO2 (usually 88-92% for COPD retainers, ≥94% for most others).
5. Obtain ABG early: Don't wait until the patient is crashing to get objective data.
6. Prepare for escalation: Noninvasive ventilation (BiPAP, CPAP) or intubation equipment at bedside.

Red Flags — Act Now