CARDIOPULMONARY ASSESSMENT

Optimal rehabilitation depends on a thorough examination of the entire patient to evaluate the
extent of dysfunction that may affect future performance. Assessment of the respiratory and
cardiovascular systems is composed of a chart review and interview, physical examination, and
review of relevant lab tests and investigations. While performing the initial examination,
objective information can be obtain from a review of medical record, an interview with the
patient, and an assessment of patient at rest (including observation, inspection, palpation,
auscultation, percussion notes, general muscle strength, joint range of motion etc.) and during
activity. In addition, the physical therapist must also have a good understanding of other
therapeutic regimens and concomitant problems and able to recognize them.

ELEMENTS OF PATIENT MANAGEMENT

The process involved in determining the most appropriate intervention to address and ultimately
achieve the desired outcomes for the patient involves six elements:
‘EEDPIO’

Examination: A comprehensive screening of history and a systemic review as well as specific

test and measures to collect data on the patient.

Evaluation: Evaluation of data from the examination to make a clinical judgment.

Diagnosis: Determining the impact of a clinical condition on function at the level of the system
and level of the individual. The diagnosis classifies a patient with in a specific practice pattern
and indicates the primary dysfunction to guide the therapist toward interventions that should be
addressed initially.

Prognosis: Determining the patient’s predicted level of optimal function as well as estimated
length of time to achieve expected improvement.

Intervention: Purposeful and skilled interaction of physical therapist with the patient, and if
appropriate, with other individuals involved in the care of patient. Using various physical therapy
procedure and techniques to produces changes in the condition/ improve condition that are
consistent with diagnosis and prognosis.

Outcomes: result of patient management, which include the impact of physical therapy
interventions in the following domains: pathology/pathophysiology, impairments, functional
limitations, disabilities, risk reduction/ prevent complication, fitness, patient satisfaction.

Once the elements have been performed, a plan of care is established. Re-examination
begins, implementing the process of performing test and measures to evaluate the patient’s
progress with subsequent modifications to the intervention.
 Components of cardiopulmonary physical therapy assessment.

Cardiopulmonary physical therapy clinical management pathway

PATIENT HISTORY

The history taking is a very critical part of the examination. Information is obtained on patient’s
current symptoms and medical problems as well as past medical history from a history, data
form, medical chart, patient/family interview and other member involved in care of patient.

CHART REVIEW & INTERVIEW

A thorough chart review and focused interview are key elements of a comprehensive assessment
of the patient with pulmonary and/or cardiovascular disorders. The physical therapist needs to
establish an open, comfortable rapport with the patient to optimize the information derived. In
addition, the therapist should have determined the purpose of the interview and possible
outcomes of treatment in order to obtain essential information and to avoid extraneous
questioning.

Chart review
The chart should be carefully reviewed before the interview. Often the chart has an immense
amount of information that is accurately recorded but it can also contain apparently conflicting or
sparse information. The therapist needs to review the chart to derive key information relevant to
physical therapy management. Depending on the manner in which this information is charted,
the therapist may ask fewer questions of the patient or simply confirm information already
recorded in the chart. In other cases, redundant questions may be posed to the patient because the
nature of his or her answer is critical to ensure accuracy of information and/or the patient's
perception of a particular issue.

Rapport
Establishing and maintaining an open, comfortable rapport with patients is essential to obtain
meaningful interview information and to implement an effective, ongoing physical therapy
management program. The ideal setting is one that affords privacy and a minimum of
distractions to both the patient and therapist. The timing of the interview should allow the patient
to be prepared for questioning and to be unhurried and relaxed. The therapist position should be
parallel to the patient if possible; both parties should be seated or situated in a comfortable
posture for the duration of the interview. Questions should be posed in an open presentation
rather than the questions being worded toward biasing the patient's response. The therapist
should be listening and recording patient response in an accepting, nonjudgmental manner as
reflected by facial expression, verbal acknowledgment, and body language.

Purpose of Interview
A variety of questions can be posed for a thorough evaluation of the patient; however, in most
clinical situations, this is not possible or warranted. The therapist's time and patient's condition
may preclude a long interview. To ensure an efficient, informative interview the therapist needs
to identify the purpose of the interview and potential outcomes of treatment to focus questioning
accordingly.
Purpose of Interviews in Different Clinical Settings

• To determine client-centered goals

• To provide information
• To determine postoperative risk for pulmonary complications
• To determine patient status immediately prior to treatment
• To determine functional capacity necessary for discharge from hospital
• To facilitate patient self-management
• To determine risks and safety issues for exercise training and other physical therapy
interventions
• To determine obstacles or challenges in implementing behavioral and lifestyle changes

Components of an Interview
The interview usually has 4 major components:

Opening: when the therapist introduces him- or herself and establishes an atmosphere of
empathy.
Questioning: when the therapist requests information usually by asking open-ended questions.
Clarification or more information may be requested. Double or ambiguous questions and
technical language should be avoided.
Responding: when the therapist clarifies or restates their interpretation of the information
provided. In addition, response by silence may be appropriate to allow the therapist to observe
the patient's nonverbal cues and to allow the patient to gather thoughts on a particular issue.
Summarizing: when the therapist might summarize the main points that the patient provided and
also informs the patient of the next stage in the treatment plan.

Content of an Interview
The content of the interviewing questions can vary dramatically in different clinical settings and
with different patients. Important issues to consider are:
• Purpose of the interview and potential outcomes of physical therapy treatment
• Information available from the chart, other reports, consults, and referral letters
• Current status of patient considering their physical, emotional, and psychological status
• Key information required to determine risks of treatment and ensure safe treatment is
carried out
• Time available by therapist and priority of patient
 Information to be derived from Chart review & Interview

Date of birth/age/ [Birth History (Important in Pediatrics)]

Current or admitting diagnosis(es)

Past Medical History

Smoking
• How much?
• When?
• Currently?

Respiratory History
• Chronic
• Acute problems
• Recent cold

Cardiovascular History
• Coronary artery disease
• Previous myocardial infarction (MI)? If so, what date?
• Previous coronary artery bypass surgery?
• Ischemic pain on exertion? ie, intermittent claudication?

Family History or Related Conditions

Cough
• Strong?
• Productive of sputum?
• Colour and consistency of sputum
• Difficulty or techniques to facilitate removal

Chest Pain
• On exertion. Angina?
• Other causes or associated factors

Other Conditions
• Diabetes
• Serious musculoskeletal
• Other

Allergens/Irritants

Problems with Previous Anesthetic

Cognitive Status
• Orientation to time, place, and person
Medications

Laboratory Investigations
• Eg, x-rays, blood tests, culture and sensitivity

Functional History
• Stairs
• Ambulation
• Mobility/activity
• Activities that are particularly tiring or difficult to do
• Regular exercise (type, duration, frequency, intensity)
• What limits exercise?
• Angina? ST changes?
• What induces angina?
• What alleviates angina?
• Dyspnea/shortness of breath?
(At rest? At night? What level of activity? Bed flat?)
• Intermittent claudication

Social History
• Occupation
• Leisure activities
• Living arrangements
• Help at home

Prior Treatment
• Related to current respiratory and/or cardiovascular conditions
• Other ongoing health care treatments that might affect or interact with physical therapy
care

Patient Goals

Established Structured Questionnaires

• Depression scores
• Health related quality of life questionnaires
• Functional status questionnaires
• Mini-mental or perceptual status
• Patient satisfaction

System Review
The system review is a brief examination of all systems that would affect the ability of the
patient to ‘initiate, sustain and modify purposeful movement for the performance of actions,
tasks or activities that are important for function”.
PHYSICAL EXAMINATION
The physical examination consists of 4 major parts:
Inspection
Measuring Vitals
Auscultation
Palpation
Mediate Percussion

INSPECTION (OBSERVATION)

Inspection is a key component in the assessment of any patient, but it is extremely important in
patients with cardiopulmonary dysfunction. The patient’s physical appearance may change
slightly as the clinical stage changes. Recognition of these slightly changes are essential to the
day-to-day management and therapeutic treatment of patient with cardiopulmonary dysfunction.
Inspection should be performed in a systemic manner, starting with the head and proceeding
caudally.

General Appearance

Level of consciousness: The patient’s level of consciousness, body type, posture and
positioning, skin tone and need for external monitoring or support equipment should be
considered in an assessment of general appearance. A patient’s level of consciousness may have
direct impact on the treatment plan. A comatose patient may require constant attention for
positioning and prevention of pulmonary dysfunction, whereas a confused patient may not
follow a therapist’s instruction without help.

Body type: Observation of body type/ built (obese, normal, cachectic) gives an indirect measure
of nutrition & exercise tolerance.

Face: Facial expression & effort of breathe are two characteristics that can be observed easily
and give important information for clinical evaluation of the patient.

• What is the patient's expression (relaxed, distressed)

• Is the patient performing pursed lip breathing
• Is the patient breathing heavily with nostril flaring
• Are the patient's lips pink or cyanotic (bluish)

In Diagram: Demonstration of pursed-lip breathing and

its effect in patients with emphysema. The weakened
bronchiole airways are kept open by the effect of positive
pressure created by the pursed lips during expiration.
Body posture & position: Body posture and position should also be assessed to determine their
impact on pulmonary system. Kyphosis and scoliosis are two postures that functionally limit
vital capacity. In addition a patient is obtaining professorial position (leaning forward on knees
or on some object) and demonstrating increased effort of breathing and use of accessory muscles,
one might begin to assume that patient has chronic obstructive disease. Most of the patients with
cardiopulmonary dysfunction cannot tolerate lying on bed with head flat and often are found
lying either in semi-fowler’s position in bed or sitting at edge of bed or in a chair.

A B

A) The professorial position provides stabilization of the thorax and arms to increases the
effectiveness of accessory muscles during breathing
B) Semi-Fowler’s position. Patients with cardiopulmonary dysfunction often require the
head of the bed elevated

Neck: The activity of the neck musculature during breathing and the appearance of the jugular
veins should be a part of the standard patient assessment. The presence of hypertrophy or
adaptive shortening of the sternocleidomastoid muscle may indicate a chronic pulmonary
condition.

In Diagram: The SCM muscles often hypertrophy in

COPD owning to increased work of accessory muscles
to assistwith breathing.
The presence of jugular venous distention should be assessed with the patient sitting or
recumbent in bed with head elevated 45 degrees. Jugular venous distention is said to be present if
JV distended above the level of the clavicles. It is an indication of increased volume in the
venous system and may be an early sign of right-sided heart failure.

Chest: Chest is evaluated in both the aspect i.e. resting as well as dynamic.

Resting

The resting chest is evaluated for its symmetry, configuration, rib angles and intercostal spaces
and musculature. Checking symmetry between sides and comparing anteroposterior and
transverse diameters provides information regarding the chronicity of cardiopulmonary
dysfunction as well as any pathologic condition.

Shape:
Anteroposterior diameter
Scoliosis/ Kyphosis
Pectus excavatum (funnel chest)
Pectus carinatum (pigeon chest)

Evaluate for the rib angle/vertebral angle and intercostals spaces should be observed for
abnormalities.

A. Normal Anteroposterior diameter A. Normal rib angle measuring less than 90

B. The increased Anteroposterior diameter in degrees and attaching at the vertebrae at
hyper inflated chest approx a 45 degrees angle.
B. Abormal rib angle greater than 90 degrees
and attaching to vertebrae at greater than
45 degrees angle.
C.
Dynamic

Dynamic chest wall is evaluated for breathing pattern, rates, inspiratory to expiratory ratios,
symmetry of chest wall movement, indrawing.

Skin

 Skin is pink or healthy

 Pallor
 Diaphoretic
 Cyanosis
 Scar/ bruises
 Incision
 Trophic changes (dry, black, scaly skin)

Extremities
Observation of the fingers and toes and calves of the leg should indicate whether long-term
problems with circulation and oxygenation are present.
Digital clubbing of fingers and toes indicates chronic tissue hypoxia and is found in many
instances of hypoxia producing diseases.

A. Normal Digit configuration

B. Digital clubbing
C. Distal phalangeal depth(DPD) is greater
than Interphanlangeal depth(IPD).

Cyanosis of nail beds may also indicate cardiopulmonary dysfunction. Cyanosis can be an
indication of decreased circulation to these areas because of cold, vasospasm, peripheral vascular
disease or decreased cardiac output.

Check for edema: type of edema, how much edema?

Lines: look for and identify every line and lead going into or leaving the patient. Ensure they are
connected properly, are not kinked, and are in a good position for their role. eg. IV lines, Oxygen
tube, NG tube, Drain tubes, Urinary catheter, ECG leads, ant saturation/temperature probe, any
other line such as Central line.
MONITORING VITALS
The monitoring of vitals is important to evaluate the baseline status of the patient as well as their
response to position change, mobilization, and exercise. Some measures, such as blood pressure,
heart rate, and respiratory rate, are immediately responsive to the environment and internal
factors of the patients. For the patient with a respiratory condition, the monitoring of oxygen
saturation (SpO2) is usually essential, whereas when assessing the patient with a cardiovascular
condition, a greater emphasis is placed on monitoring HR, BP, and electrocardiogram (ECG) as
indicated.

AUSCULTATION
Auscultation is an evaluation technique used to listen and interpret the sounds produced within
the thorax. Auscultation is also an excellent tool for reassessment of an individual’s ventilation
following treatment techniques to improve bronchial hygiene or regional ventilation.
Auscultation requires appropriate equipment (the stethoscope) as well as proper
instruction to patient and proper positioning.
For auscultation of the lung sounds, the optimal position is for the patient to be sitting to permit
auscultation of entire lung spaces, including both anterior and posterior chest wall. In addition,
optimal auscultation involves removal of bed clothes to expose the bare skin while the individual
breathes deeply. The auscultation should be performed over the entire lung space. The intensity,
pitch and quality of breath sounds should be compared between right and left and in apical to
dome of diaphragm direction.

A. Auscultating the chest anteriorly

B. Auscultating the chest posteriorly
Technique of Auscultation
 Explain the auscultation technique to the patient in a clear manner using laymen's terms.
 If possible, position the patient in an upright position, and remove or drape clothing to
facilitate easy access to anterior, lateral, and posterior auscultation points. Thorough
explanation and appropriate draping is especially important when auscultating female
patients.
 Instruct patient to take "deep" breaths in and out of his or her mouth and allow patient to
rest periodically (after 5 to 10 breaths depending on his or her tolerance).
 While holding a stethoscope in an appropriate manner with its diaphragm against skin of
chest wall, position the stethoscope diaphragm at the uppermost point anteriorly. Listen at
this auscultation point for 1 complete respiratory cycle while the patient is breathing in
and out of his or her mouth. Next, proceed to the contralateral side and then downward
from side to side, listening for a complete respiratory cycle at each auscultation point.

Errors of Auscultation to avoid

Errors Correct Technique

Listening to breath sound through the Placing diaphragm directly over chest wall
patient’s gown
Allowing tubing to rub against bed rails or Keeping tubing free from contact with any
patient’s gown objects during auscultation
Attempting to auscultation in noisy room Turning the television or radio off
Interpreting chest hair sounds as adventitious Wetting chest hair before auscultation
lung sound
Auscultating only the convenient areas Auscultated over the entire lung fields

Lung Sounds
Lung sounds are heard on auscultation over healthy lungs. There may be some variation in
quality depending on the thickness and quality of chest wall tissue. Very thin people may have
more bronchovesicular breath sounds whereas people with increased subcutaneous fat may have
decreased breath sounds.
Disagreements exist regarding the terms used to auscultated lung sounds. Nonetheless, lung
sounds may be divided into two types: Normal Breath Sounds and Abnormal & Adventitious
lung sounds.

NORMAL BREATH SOUND

Normal breath sounds are heard on auscultation over healthy lungs. There may be some variation
in quality depending on the thickness and quality of chest wall tissue. Very thin people may have
more bronchovesicular breath sounds whereas people with increased subcutaneous fat may have
decreased breath sounds.
 Breath sound Quality/Nature Location Respiratory cycle
Normal or Vesicular Soft/ low pitched Most lung fields/ Inspiration and beginning of
Peripheral lungs expiration without pause
Bronchovesicular Combination of Heard over main Inspiration and expiration
vesicular & stem bronchi without pause
bronchovesicular
Bronchial Harsh, hollow, high- Over trachea Inspiration & expiration.
pitched Pause between Inspiration &
expiration.

A) a) Tracheal/Bronchial breath sound B) The position of the anterior and posterior chest
b) Bronchovesicular breath sound wall at which normal vesicular & bronchovesicular
c) Vesicular breath sound breath sound are heard

ABNORMAL BREATH SOUND

Abnormal breath sounds are heard on auscultation over unhealthy regions of the lung with
different pathologies. The lung pathology may be within the lung tissue or between the chest
wall and lungs.
Bronchial Sounds: Bronchial sounds over peripheral lung fields is an abnormal sound that
is heard over consolidation, which acts acoustically like a lump of meat in the lung, the solid
medium transmitting sounds more clearly than air-filled lung. Bronchial breathing can also be
heard over the upper level of a pleural effusion. Bronchial breath sounds indicate loss of
functioning lung volume.

Breath Sound Condition

Bronchial Consolidated pneumonia
Decreased or Absent Pleural effusion, Heamothorax, Pneumothorax,
Emphysema, obese, elderly
Diminished breath sounds: are heard if:
• The patient is obese, in a poor position or not breathing deeply
• There is no air entry to generate the sound,e.g. atelectasis with occluded airway
• There is air entry but transmission of sound is deflected by an acoustic barrier such as the air-
solid or air-liquid interface of a pneumothorax or pleural effusion
• There is air entry but insufficient airflow to generate sound, or excess air in the lung that filters
sound, e.g. hyperinflation as in emphysema or acute asthma

ADVENTITIOUS LUNG SOUND

Adventitious lung sounds are extra lung sounds. These are the added sounds which superimposed
on the breath sound. These can be divided into two categories: Continuous and Discontinuous
lung sound. The American Thoracic Society and The American college of Chest Physician
further clarified the continuous sounds as Wheezes (previously known as rhonchi) and
discontinuous adventitious sound as crackles (previously known as rales).

Adventitious sound Type Quality/ Nature Condition

Crackles (I) Discontinuous Fine (High pitched) Atelectasis, Interstitial pulmonary
fibrosis,
Coarse (Medium or Retained secretion
low pitched)
Wheezes (E) Continuous High or Medium Bronchospasm, Pulmonary edema,
pitched COPD
Low pitched Retained secretions in large
airways
Pleural rub: Pleural rub is also an abnormal breath sound that should be checked by auscultation
in the lower lateral chest bilaterally. It is an indication of pleural inflammation. The pleural rub
sounds like two pieces of sand paper rubbing together and it occur with each inspiration and
expiration.

Heart Sounds

Auscultation of heart requires selective listening for each component of cardiac cycle while
placing the stethoscope on four main topographic areas for auscultation.

The Aortic area: auscultated best in the second intercostals space closed to the sternum on the
right side of the sternum.
The Pulmonary area: auscultated best in the second intercostals space closed to the sternum on
the left side of the sternum.
The Tricuspid area: auscultated best at the lower left sternal border, 4th or 5th intercostals space.
The Mitral area(apex of heart): located in the fifth left intercostals space, medial to midclavicular
line.

As with breath sounds auscultation of heart sound should be performed in a systemic

manner, such as by beginning at the aortic area and listening the both the first and second heart
sounds. When listening the sound, intensity and timing, any splitting, extra sounds, or murmurs
should be noted.

The first heart sound, S1 ( the lub of lub-dub), is associated with the closure of mitral and
tricuspid valves and correspond with the onset of ventricular systole. The S1 sound is normally
louder, and longer and low pitched when auscultated over the apex or even in the tricuspid
region.

The Second heart sound, S2 ( the dub of lub-dub), is associated with the closure of aortic and
pulmonary valves and correspond with the starts of ventricular diastole. The S2 sound is of
greater intensity when auscultated over aortic or pulmonary region.

ABNORMAL HEART SOUNDS

Third heart sound (S3) occurs early in diastole while ventricles are rapidly filling (immediately
following S2 and sounds like lub-dub-dub).

Fourth heart sound (S4) occurs late in diastole (just before S1 and sounds like la-lub-dub). It is
associated with atrial contraction. It is a low pitched sound and associated with increased
resistance to ventricular filling. It is commonly heard in individual with HTN, CAD, individual
with history of MI or CABG.
Murmurs: Murmur can be very complex and difficult to understand for entry level practitioner.
However, there are three broad classifications of murmurs that can help one understand the
mechanism of murmurs:

Murmurs caused by high rate of flow either through normal or abnormal valves

Murmurs caused by forward flow through a stenotic valve or by flow into a dilated vessel or
chamber.

Murmurs caused by backward flow through a valve(regurgitation).

PALPATION

Palpation is an assessment technique employed to refine the information gathered from the chart
review, inspection and auscultation. The purpose of palpation is to evaluate the mediastinum,
chest motion. Chest wall pain, fermitus, muscles activity of chest wall and diaphragm, and the
circulatory status.

The mediastinum (Tracheal position)

Evaluation of mediastinum assesses the tracheal shift that is due to disproportionate intrathoracic
pressure or lung volume between both lungs. The content of the mediastinum shift toward the
affected side when the lung volume or intrathoracic pressure on that side is decreased. This can
happen following a lobectomy or pneumonectomy or a lung collapse. The content of
mediastinum shifted to unaffected side (contralateral side) when the pressure on the same side is
increased. This can happens in a pleural effusion, pneumothorax, tumor.

Palpation for such shifts is performed while the patient is sitting upright with the neck slightly
flexed to relaxation of SCM and chin should be positioned in midline. Palpation proceed with the
tip of index finger being placed in supra sterna notch, first medially to left sternoclavicular joint
and pushed inward toward the cervical spine. Then medially to right sternoclavicular joint.
Check for the shifting of trachea.
Chest Expansion
Palpation is performed segmentally to confirm the chest wall expension over the upper, middle,
lower lobes while the patient is breathing quietly and deeply. The important components of
evaluation are amount of hand movement, symmetry of movement and timing of movement.
Both sides should move equally, with 3-5 cm being the normal displacement.

The upper chest wall expansion is evaluated by the therapist placing the palms of hands
anteriorly over the chest wall from the fourth rib upwards. The fingers should be stretched over
the trapezius and the thumbs should be placed together along the midline of the chest. The
patient should be asked to take a maximal inspiration, and the therapist hands should be relaxed
so that they move along with the chest wall. Extent of movement and symmetry of movement is
important.

The middle chest wall is evaluated by placing the finger laterally over the posterior axillary fold
with the pals firmly placed on the anterior chest wall.

The lower chest wall is evaluated with the patient back toward the therapist. The therapist fingers
wrap around the anterior axillary fold and the tips of thumbs meet at the spinal column.
Vocal Fremitus

Fremitus is defined as the vibration that is produced by the voice or by presence of secretions in
the airways and is transmitted to the chest wall and palpated by hands. Palpation of fermitus is
performed with the hands placed lightly on the chest wall while the patients repeats some word,
such as 99 to distinguish normal fermitus from the abnormal fremitus. Increased fermitus
indicate secretions in that particular area and decreased fermitus indicate that increased air in that
particular region.

Evaluation of muscle activity of chest wall and diaphragm

To evaluate the amount of accessory muscle activity used during quiet breathing. By palpating
the accessory muscles, particularly scalenes and the trapezii, an amount of work of breathing
may be noted. In addition, the extent of diaphragmatic contribution can be assesd with the patient
in supine position. Palpation of anterior chest wall with the thumbs over the costal margins and
thumb tips meeting at the xiphoid process. Normally total circumferential diameter increasing by
at least 2 to 3 inches at deep inspiration. The extent of movement is important part of assessment
of diaphragm excursion. E.g An indidual with COPD increases the muscles activity of accessory
muscles and decreased diaphragm excursion.

Circulation

Pulses throughout the extremities should be palpated during initial examination.

Location for pulse palpation: Radial, Brachial, carotid, Femoral, Popliteal, Posterior tibial,
dorsalis pedis.

Quality of pulse should be noted and a comparison should be made to the pulse of opposite
extremity.
Mediate Percussion

Mediate percussion is performed to rule out the changes in the lung density.

Percussion is performed with the middle finger of one hand placed falt on the chest wall along
the intercostals space, while the other finger are lifted off the chest wall. The other hand is
positioned with the wrist in dorsiflexion, acting like a fulcrum and tip of middle finger is striking
on the DIP joint of the middle finger of another hand placed on chest wall. Percussion usually
proceeds in a cephalocaudal direction and back and forth in right and left sides, anteriorly and
posteriorly.

Resonance is generated by the chest wall vibrating over the underlying tissues. Normal
resonance is heard over aerated lung, whilst consolidated lung sounds dull, and a pleural effusion
sounds 'stony duIl'. Increased resonance is heard when the chest wall is free to vibrate over an
air-filled space, such as a pneumothorax or bulla.
Respiratory Rate & Rhythm
Normal ventilation is an automatic, seemingly effortless inspiratory expansion and expiratory
contraction of the chest cage. Normal breathing should be regular with a rate of 12-16 breaths
per min. Inspiration is active and expiration passive. The approximate ratio of inspiratory to
expiratory time (I: E ratio) is 1:1.5 to 1:2.

An adult breathes from 16 to 20 breaths per minute.

Children breathe at a rate of 20 to 28 breaths per minute.
Infants have a normal range of 30 to 50 breaths per minute.

Depth of the breath

The depth of ventilation is the amount of air that inhaled and exhaled.
The amount of air inhaled and exhaled in one cycle is called the tidal volume.
The greater degree that the chest expands, the more the depth of the ventilation.
Extreme expansion of the chest wall with extreme relaxation on exhalation indicates adequate
depth of breathing and adequate tidal volume.

 Normal The chest does not expand to its full capacity with each breath in normal depth of
breathing so hard to determine ‘normal’. If a patient is not showing any sign of distress, is
alert, and has normal pallor (skin colour), then it is fair to say the breathing depth is normal
and adequate.
 Shallow Slight rise and fall of a patient’s chest and abdomen would represent shallow
breathing. The patient will probably breathe at a rapid rate. The combination of rapid, shallow
breathing is said to be “short of breath.” and will not get an enough tidal volume to allow the
air to reach the lungs for good oxygenation. A pattern of slow, shallow breathing is called
hypoventilation.
 Deep When the chest cavity expands to almost its full capacity. And in the manner of gasping
for air with a pattern of rapid, deep breathing, this is called hyperventilation.

Rhythm
A regular, oscillating cycle of inspiration and expiration, controlled by neuronal impulses
transmitted between the respiratory centers in the brain and the muscles of inspiration in the
chest and diaphragm. The normal breathing pattern may be altered by a variety of conditions.

 Regular The normal breathing pattern or rhythm is: inhalation, pause, exhalation, pause.
Exhalation lasts about twice as long as inhalation phase and repeated at a steady pace.
 Irregular. A change from the normal breathing pattern is an irregular pattern. An irregular
breathing pattern may indicate the presence of illness.
Apnea: Absence of breathing more than 15 seconds.
Sleep apnea is cessation of breathing, especially during sleep. The most common type is
Adult Sleep APNEA.
Central apnea in which there is failure of the central nervous system drive to respiration
sometimes occurs in infants younger than 40 weeks after the date of conception.

Eupnea: Normal RR, normal depth, regular rhythm.

Bradypnea: Decreased in RR, shallow or normal depth, regular rhythm, associated with diabetic
come, drug overdose (drug induced respiratory depression), increased ICP.

Tachypnea: Increased RR, shallow depth, regular rhythm associated with RLD.

Hyperpnea: Normal rate, increased depth, regular rhythm

Apneustic breathing: A pattern of breathing characterized by a prolonged inspiratory phase

followed by expiration apnea. The rate of apneustic breathing is usually around 1.5 breaths per
minute. This breathing pattern is often associated with head injury

Cheney-Stokes (Periodic): Refers to irregular breathing with cycles consisting of a few

relatively deep breaths, progressively shallower breaths (sometimes to the point of apnea), and
then slowly increasing depth of breaths. This is usually associated with heart failure, severe
neurological disturbances, or drugs (e.g. narcotics).

Biot’s respiration: Breathing characterized by irregular periods of apnea alternating with

periods in which four or five breaths of identical depth are taken; seen in patients with increased
intracranial pressure associated with spinal meningitis and other central nervous system
disorders.

Prolonged expiration: May be seen in patients with obstructive lung disease, where expiratory
airflow is severely limited by dynamic closure of the smaller airways. In severe obstruction the
I:E ratio may increase to 1:3 or 1:4

Hyperventilation: Abnormally fast and deep breathing, the result of either an emotional state or
a physiological condition. Emotional causes include acute anxiety and emotional tension, such as
in nervous, anxious patients who may have other functional disturbances related to emotional
problems. Results in decreased CO2, called ‘Kussmaul breathing’ in metabolic acidosis. Also
associated with CNS disorders like encephalitis.

Ataxic breathing: Consists of haphazard, uncoordinated deep and shallow breams. This may be
found in patients with cerebellar disease.

Paradoxical breathing: Is where some or the entire chest wall moves inwards on inspiration and
outwards on expiration. It can involve anything from a localized area to the entire chest wall.
Dyspnea (shortness of breath): Rapid rate, shallow depth, regular rhythm; associated with
accessory muscle activity.

Scales of Dyspnea:

1. Modified Borg Dyspnea Scale

0 Nothing at all
0.5 Very, very Slight (Just
noticable)
1 Very slight
2 Slight
3 Moderate
4 Somewhat severe
5 Severe
6
7 Very severe
8
9 Very, very severe (almost
maximal)
10 Maximal

2. Modified Medical Research Council Dyspnea Scale