RESPIRATORY STATUS AND PERFUSION ASSESSMENT

NORMAL RESPIRATORY DISTRESS (#)

Distressed, anxious, obviously fighting for breath,

General appearance Calm, quiet, not anxious
exhausted. Decreased level of consciousness

Normal sentences, with no

Speech Short sentences  phrases  words only  none
difficulty

Respiratory Noises Cough

(heard without a Audible wheeze on exhalation;
Quiet, no noises
stethoscope) “Crackly” moist sounds;
Inspiratory stridor.

Wheeze: expiratory; occ inspiratory as well

Quiet, no wheezes or Crackles fine  coarse;
Chest auscultation
crackles bases  mid zone  full field
Silent chest – one side, or bilateral

Adults: 12 – 16 / minute Tachypnoea - adults > 24 / min

Respiratory rate Kids: 15 – 25 / minute - kids > 35 / min
Babies: 20 – 40 / minute - babies > 50 / min

Marked chest / abdo movement; use of accessory

Minimal apparent effort;
Respiratory effort
small chest / abdo movement
muscles; intercostal recession; sternal retraction;
tracheal tug
(NOTE: chest movement may be minimal with some
conditions)

Adults: 60 – 80 / min (*)Tachycardia - adults > 100 / min

Kids: 80 – 120 - kids > 130
Pulse rate Babies: 100 – 140 - babies > 150
(slow pulse rate is a late sign in severe cases)

Sweaty; sometimes pale

Skin Pink; normal May be flushed
Cyanosis is a late sign

Conscious state Alert; orientated Altered

90 – 95% on room air;

Oximetry 96% + on room air
< 90% = serious hypoxia

NOTE: This assessment applies to patients with respiratory distress from any cause

(#) Any of these features may indicate respiratory distress.

The more that are present, the greater the degree of respiratory distress.
(*) Some patients, especially older patients, may be on medication that prevent
the development of tachycardia.

ACT Ambulance Service Clinical Management Manual

Uncontrolled when printed. The latest version of this document is available on the ACT Ambulance Service internet site.
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