Respiratory Rate
at the bedside
- definitions → normal 12–20 breaths/min · tachypnea > 20 · bradypnea < 12
- confirm → count yourself for a full minute
- note depth, work of breathing, ability to speak in sentences, O₂ device and flow, SpO₂, mental state, BP
- hypoxemic or O₂ requirement rising → oxygen desaturation
escalate now if
- RR ≥ 30 or < 8, or rising fast
- apnea, gasping or ineffective breathing; cannot protect the airway → bradypnea, arrest call
- severe work of breathing or exhaustion → hypoxemia, ICU
- altered consciousness → hypercapnia
- persistent hypoxemia or rising O₂ requirement → hypoxemia
- acute hypercapnic acidosis on the gas → hypercapnia, NIV
- hemodynamic instability → hypotension; fast and deep with a clear chest → metabolic acidosis
focused check
- onset, trend, baseline RR and O₂ requirement
- cause by the story
- cough, sputum, fever, pleuritic pain → pneumonia
- wheeze, tight chest → asthma / COPD
- sudden pleuritic pain, hemoptysis, leg swelling, immobility → PE
- sudden unilateral pain, reduced breath sounds → pneumothorax
- orthopnea, edema, weight gain → pulmonary edema
- chest pain, palpitations → ACS / arrhythmia
- vomiting, polyuria, renal disease, sepsis → metabolic acidosis, DKA
- opioids, sedatives, alcohol; head injury, stroke, seizure, neuromuscular weakness → hypoventilation
- pain, anxiety, fever, anemia
- examine → airway; effort, accessory muscles, ability to speak; wheeze, crackles, unequal or absent air entry; JVP, edema, perfusion; consciousness, pupils; signs of DVT
send now
- VBG with lactate for pH and CO₂; ABG when you need PaO₂ or an exact PaCO₂
- glucose, ketones, RFT, CBC, CRP
- ECG; CXR
- by cause → troponin, blood cultures, bedside echo; NT-proBNP if heart failure is in question (< 300 pg/mL makes it unlikely)
- PE suspected → Wells score · MDCalc ↗︎ first; D-dimer only if probability is low to intermediate; CTPA if indicated
calculator NEWS2 · MDCalc ↗︎
treat
hypoxemia
- oxygen to target and treat the cause → oxygen desaturation
- support escalates O₂ → HFNO → NIV → intubation by work of breathing and the gas: ICU early
hypercapnia / hypoventilation
- at risk of CO₂ retention → controlled O₂ to 88–92%; ABG
- treat the cause → nebulisers and steroids for COPD, reverse sedatives and opioids, clear secretions
- COPD exacerbation with pH ≤ 7.35, PaCO₂ > 45 mmHg and RR > 20–24 despite initial treatment → bilevel NIV; hypercapnic but not acidotic → no NIV
- cardiogenic pulmonary edema with respiratory failure → CPAP or NIV
- reduced consciousness, cannot protect the airway, exhausted, NIV failing or acidosis worsening → ICU and anesthesia now for intubation
suspected opioid toxicity
- bag-mask ventilate first if breathing is inadequate
- on prescribed opioids → naloxone 0.1 mg IV, repeat every 2–3 min to adequate breathing, not full arousal; 0.4 mg IV/IM if peri-arrest → analgesia
- over-reversal causes severe pain, withdrawal, agitation, pulmonary edema
- recurs → naloxone IV infusion at two-thirds of the effective bolus dose per hour; observe for hours after the last dose, longer with methadone, modified-release morphine or buprenorphine
- overdose or apnea → naloxone 0.4–2 mg IV, repeat every 2–3 min with ventilation; no response → reconsider the diagnosis
- senior, toxicology or ICU early if recurrent, unclear or not responding
compensatory tachypnea, metabolic acidosis
- never sedate or suppress it
- treat the cause → DKA → hyperglycemia; sepsis, lactic acidosis, renal failure, salicylates
- intubation in severe acidosis is high risk: ICU and anesthesia early
bradypnea
- airway; bag-mask if breathing is inadequate: oxygen alone does not treat failing ventilation
- opioids and sedatives (box above), neurological injury, raised ICP, hypothermia, neuromuscular weakness
- hand over → RR and effort trend, O₂ requirement, last gas, escalation trigger
evidence
| source | type |
|---|---|
| RCP NEWS2 (Dec 2017, current) | international guideline |
| ERS/ATS 2017 noninvasive ventilation for acute respiratory failure | international guideline |
| BMJ 2018 Rapid Recommendation, oxygen therapy for acutely ill medical patients | international guideline |
| 2025 AHA ECC guidelines, opioid-associated emergencies | international guideline |
| Kuwait MOH naloxone / opioid-reversal protocol | local-protocol verification required |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
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reviewed 17 Aug 2026updated Oct 2026file vital/respiratory-rate