Respirations, shallow

Respirations are shallow when a diminished volume of air enters the lungs during inspiration. In an effort to obtain enough air, the patient with shallow respirations usually breathes at an accelerated rate. However, as he tires or as his muscles weaken, this compensatory increase in respirations diminishes, leading to inadequate gas exchange and such signs as dyspnea, cyanosis, confusion, agitation, loss of consciousness, and tachycardia.

Shallow respirations may develop suddenly or gradually and may last briefly or become chronic. They’re a key sign of respiratory distress and neurologic deterioration. Causes include inadequate central respiratory control over breathing, neuromuscular disorders, increased resistance to airflow into the lungs, respiratory muscle fatigue or weakness, voluntary alterations in breathing, decreased activity from prolonged bed rest, and pain.

Emergency interventions

 If you observe shallow respirations, be alert for impending respiratory failure or arrest. Is the patient severely dyspneic? Agitated or frightened? Look for signs of airway obstruction. If the patient is choking, perform a four back blows and then four abdominal thrusts, to try to expel the foreign object. Use suction if secretions occlude the patient’s airway.

If the patient is also wheezing, check for stridor, nasal flaring, and use of accessory muscles. Administer oxygen with a face mask or a handheld resuscitation bag. Attempt to calm the patient. Administer epinephrine I.V.

If the patient loses consciousness, insert an artificial airway and prepare for endotracheal intubation and ventilatory support. Measure his tidal volume and minute volume with a Wright respirometer to determine the need for mechanical ventilation. (See Measuring lung volumes, page 682.) Check arterial blood gas (ABG) levels, heart rate, blood pressure, and oxygen saturation. Tachycardia, increased or decreased blood pressure, poor minute volume, and deteriorating ABGs or oxygen saturation signal the need for intubation and mechanical ventilation.

History and physical examination

If the patient isn’t in severe respiratory distress, begin with the history. Ask about chronic illness and any surgery or trauma. Has he had a tetanus booster in the past 10 years? Does he have asthma, allergies, or a history of heart failure or vascular disease? Does he have a chronic respiratory disorder or respiratory tract infection, tuberculosis, or a neurologic or neuromuscular disease? Does he smoke? Obtain a drug history, too, and explore the possibility of drug abuse.

Ask about the patient’s shallow respirations: When did they begin? How long do they last? What makes them subside? What aggravates them? Ask about changes in appetite, weight, activity level, and behavior.

Begin the physical examination by assessing the patient’s level of consciousness and his orientation to time, person, and place. Observe spontaneous movements, and test muscle strength and deep tendon reflexes. Next, inspect the chest for deformities or abnormal movements such as intercostal retractions. Inspect the extremities for cyanosis and digital clubbing.

Palpate for expansion and diaphragmatic tactile fremitus, and percuss for hyperresonance or dullness. Auscultate for diminished, absent, or adventitious breath sounds and for abnormal or distant heart sounds. Do you note any peripheral edema? Finally, examine the abdomen for distention, tenderness, or masses.

Medical causes

Acute respiratory distress syndrome

Initially, this life-threatening syndrome produces rapid, shallow respirations and dyspnea, at times after the patient appears stable. Hypoxemia leads to intercostal and suprasternal retractions, diaphoresis, and fluid accumulation, causing rhonchi and crackles. As hypoxemia worsens, the patient exhibits more difficulty breathing, restlessness, apprehension, decreased level of consciousness, cyanosis and, possibly, tachycardia.

Amyotrophic lateral sclerosis (ALS)

Respiratory muscle weakness in this disorder causes progressive shallow respirations. Exertion may result in increased weakness and respiratory distress. ALS initially produces upper extremity muscle weakness and wasting, which in several years affect the trunk, neck, tongue, and muscles of the larynx, pharynx, and lower extremities. Associated signs and symptoms include muscle cramps and atrophy, hyperreflexia, slight spasticity of the legs, coarse fasciculations of the affected muscle, impaired speech, and difficulty chewing and swallowing.

Asthma

With this disorder, bronchospasm and hyperinflation of the lungs cause rapid, shallow respirations. In adults, mild persistent signs and symptoms may worsen during severe attacks. Related respiratory effects include wheezing, rhonchi, a dry cough, dyspnea, prolonged expirations, intercostal and supraclavicular retractions on inspiration, nasal flaring, and use of accessory muscles. Chest tightness, tachycardia, diaphoresis, and flushing or cyanosis may occur.

Atelectasis

Decreased lung expansion or pleuritic pain causes sudden onset of rapid, shallow respirations. Other signs and symptoms include a dry cough, dyspnea, tachycardia, anxiety, cyanosis, and diaphoresis. Examination reveals dullness to percussion, decreased breath sounds and vocal fremitus, inspiratory lag, and substernal or intercostal retractions.

Botulism

With this disorder, progressive muscle weakness and paralysis initially cause shallow respirations. Within 4 days, the patient develops respiratory distress from respiratory muscle paralysis. Early signs and symptoms include bilateral mydriasis and nonreactive pupils, anorexia, nausea, vomiting, diarrhea, dry mouth, blurred vision, diplopia, ptosis, strabismus, and extraocular muscle palsies. Others quickly follow, including vertigo, deafness, hoarseness, constipation, nasal voice, dysarthria, and dysphagia.

Bronchiectasis

Increased secretions obstruct airflow in the lungs, leading to shallow respirations and a productive cough with copious, foul-smelling, mucopurulent sputum (a classic finding). Other findings include hemoptysis, wheezing, rhonchi, coarse crackles during inspiration, and late-stage clubbing. The patient may complain of weight loss, fatigue, exertional weakness and dyspnea on, fever, malaise, and halitosis.

Chronic bronchitis

Airway obstruction causes chronic shallow respirations. This disorder may begin with a nonproductive, hacking cough that later becomes productive. It may also cause prolonged expirations, wheezing, dyspnea, accessory muscle use, barrel chest, cyanosis, tachypnea, scattered rhonchi, coarse crackles, and clubbing (a late sign).

Coma

Rapid, shallow respirations result from neurologic dysfunction or restricted chest movement.

Emphysema

Increased breathing effort causes muscle fatigue, leading to chronic shallow respirations. The patient may also display dyspnea, anorexia, malaise, tachypnea, diminished breath sounds, cyanosis, pursed-lip breathing, accessory muscle use, barrel chest, chronic productive cough, and clubbing (a late sign).

Flail chest

With this disorder, decreased air movement results in rapid, shallow respirations, paradoxical chest wall motion from rib instability, tachycardia, hypotension, ecchymoses, cyanosis, and pain over the affected area.

Fractured ribs

Pain on inspiration and possibly expiration may cause shallow respirations.

Guillain-Barré syndrome

Progressive ascending paralysis causes rapid or progressive onset of shallow respirations. Muscle weakness begins in the lower limbs and extends finally to the face. Associated findings include paresthesia, dysarthria, diminished or absent corneal reflex, nasal speech, dysphagia, ipsilateral loss of facial muscle control, and flaccid paralysis.

Kyphoscoliosis

Skeletal cage distortion can eventually cause rapid, shallow respirations from reduced lung capacity. It also causes back pain, fatigue, tracheal deviation, and dyspnea.

Multiple sclerosis

Muscle weakness causes progressive shallow respirations. Early features include diplopia, blurred vision, and paresthesia. Other possible findings are nystagmus, constipation, paralysis, spasticity, hyperreflexia, intention tremor, ataxic gait, dysphagia, dysarthria, urinary dysfunction, impotence, and emotional lability.

Muscular dystrophy

With progressive thoracic deformity and muscle weakness, shallow respirations may occur along with waddling gait, contractures, scoliosis, lordosis, and muscle atrophy or hypertrophy.

Myasthenia gravis

Progression of this disorder causes respiratory muscle weakness marked by shallow respirations, dyspnea, and cyanosis. Other effects include fatigue, weak eye closure, ptosis, diplopia, and difficulty chewing and swallowing.

Obesity

Morbid obesity may cause shallow respirations due to the work of breathing associated with movement of the chest wall. Heart and breath sounds may be distant.

Parkinson’s disease

Fatigue and weakness lead to progressive shallow respirations. Typically, this disorder slowly progresses to increased rigidity (lead-pipe or cogwheel), masklike facies, stooped posture, shuffling gait, dysphagia, drooling, dysarthria, and pill-rolling tremor.

Pleural effusion

With this disorder, restricted lung expansion causes shallow respirations, beginning suddenly or gradually. Other findings include nonproductive cough, weight loss, dyspnea, and pleuritic chest pain. Examination reveals pleural friction rub, tachycardia, tachypnea, decreased chest motion, flatness to percussion, egophony, decreased or absent breath sounds, and decreased tactile fremitus.

Pneumonia

Pulmonary consolidation results in rapid, shallow respirations. The patient may experience dyspnea, fever, shaking chills, chest pain, cough, tachycardia, decreased breath sounds, crackles, and rhonchi. He may also develop myalgias, fatigue, anorexia, headache, abdominal pain, cyanosis, and diaphoresis.

Pneumothorax

This disorder causes sudden onset of shallow respirations and dyspnea. Related effects include tachycardia; tachypnea; sudden sharp, severe chest pain (commonly unilateral) worsening with movement; nonproductive cough; cyanosis; accessory muscle use; asymmetrical chest expansion; anxiety; restlessness; hyperresonance or tympany on the affected side; subcutaneous crepitation; decreased vocal fremitus; and diminished or absent breath sounds on the affected side.

Pulmonary edema

Pulmonary vascular congestion causes rapid, shallow respirations. Early signs and symptoms include exertional dyspnea, paroxysmal nocturnal dyspnea, nonproductive cough, tachycardia, tachypnea, dependent crackles, and a ventricular gallop. Severe pulmonary edema produces more rapid, labored respirations; widespread crackles; a productive cough with frothy, bloody sputum; worsening tachycardia; arrhythmias; cold, clammy skin; cyanosis; hypotension; and thready pulse.

Pulmonary embolism

This disorder causes sudden, rapid, shallow respirations and severe dyspnea with angina or pleuritic chest pain. Other clinical features include tachycardia, tachypnea, a nonproductive cough or a productive cough with blood-tinged sputum, low-grade fever, restlessness, diaphoresis, pleural friction rub, crackles, diffuse wheezing, dullness to percussion, decreased breath sounds, and signs of circulatory collapse. Less-common findings are massive hemoptysis, chest splinting, leg edema, and (with a large embolism) cyanosis, syncope, and jugular vein distention.

Spinal cord injury

Diaphragmatic breathing and shallow respirations may occur in injury to the C5 to C8 area. Other findings include quadriplegia with flaccidity followed by spastic paralysis, areflexia, hypotension, sensory loss below the level of injury, and bowel and bladder incontinence.

Tetanus

With this now-rare disorder, spasm of the intercostal muscles and the diaphragm causes shallow respirations. Late findings typically include jaw pain and stiffening, difficulty opening the mouth, tachycardia, profuse diaphoresis, hyperactive deep tendon reflexes, and opisthotonos.

Upper airway obstruction

Partial airway obstruction causes acute shallow respirations with sudden gagging and dry, paroxysmal coughing; hoarseness; stridor; and tachycardia. Other findings include dyspnea, decreased breath sounds, wheezing, and cyanosis.

Other causes

Drugs

Opioids, sedatives and hypnotics, tranquilizers, neuromuscular blockers, magnesium sulfate, and anesthetics can produce slow, shallow respirations.

Surgery

After abdominal or thoracic surgery, pain associated with chest splinting and decreased chest wall motion may cause shallow respirations.

Special considerations

Prepare the patient for diagnostic tests: ABG analysis, pulmonary function tests, chest X-rays, or bronchoscopy.

Position the patient as nearly upright as possible to ease his breathing. (Help a postoperative patient splint his incision while coughing.) If he’s taking a drug that depresses respirations, follow all precautions, and monitor him closely. Ensure adequate hydration, and use humidification as needed to thin secretions and to relieve inflamed, dry, or irritated airway mucosa. Administer humidified oxygen, a bronchodilator, a mucolytic, an expectorant, or an antibiotic, as ordered.

Turn the patient frequently. He may require chest physiotherapy, incentive spirometry, or intermittent positive-pressure breathing. Monitor the patient for increasing lethargy, which may indicate rising carbon dioxide levels. Have emergency equipment at the patient’s bedside.

Pediatric pointers

In children, shallow respirations commonly indicate a life-threatening condition. Airway obstruction can occur rapidly because of the narrow passageways; if it does, administer back blows or chest thrusts but not abdominal thrusts, which can damage internal organs.

Causes of shallow respirations in infants and children include idiopathic (infant) respiratory distress syndrome, acute epiglottiditis, diphtheria, aspiration of a foreign body, croup, acute bronchiolitis, cystic fibrosis, and bacterial pneumonia.

Observe the child to detect apnea. As needed, use humidification and suction, and administer supplemental oxygen. Give parenteral fluids to ensure adequate hydration. Chest physiotherapy may be required.

Geriatric pointers

Stiffness or deformity of the chest wall associated with aging may cause shallow respirations.

Patient counseling

Have the patient cough and deep-breathe every hour to clear secretions and to counteract possible hypoventilation. Provide assistance with tracheal suctioning as needed.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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