The four vital signs are taken at routine clinic visits. In previous posts, I’ve discussed blood pressure, heart rate and temperature. Respiratory rate is the 4th classic vital sign. Respiratory rate is the number of breaths that a person takes in a minute.
The normal rate of breathing varies with age. Babies and children breath faster than adults. As we age, our lung capacity starts to decrease, and the respiratory rate goes up slightly. The normal range for an older adult is a respiratory rate of 14-20 at rest.
Most seniors have a chronic condition. Hypertension, heart disease, atrial fibrillation, or diabetes are common. For these seniors, checking the blood pressure and heart rate at least daily is a good practice. Many medicines effect these measurements. It is good to establish a baseline awareness of what is normal for each person. Diabetic patients should also check their blood sugars at least daily.
Most stable older patients do NOT need to check a temperature and a respiratory rate daily. However, both measurements should be checked when a person is starting to look or feel ill. A feverish feeling or shortness of breath are also important signs of acute illness. Check all vital signs when you are concerned that a person is acutely ill.
At rest while awake, an older person normally takes 14 to 20 breaths a minute. The respiratory rate can go higher with exertion such as walking or going up stairs. Too fast of a respiratory rate indicates that the body is working too hard. A very healthy senior can tolerate a respiratory rate as fast as 30 with exercise. For people who are frail, avoid exceeding a respiratory rate greater than 24.
Caregivers should be aware of a patient’s usual respiratory rate. A change in respiratory rate, too slow or too fast, may indicate that something is wrong.
This is a person who has severe COPD on chronic oxygen supplement. He is likely to have vital signs that are not typical of healthier people. The heart rate is slightly faster in the range of 85-90. Respiratory rate is in the range of 18-22 at rest. Even with oxygen, the O2 saturation may be 95%. This patient can become short of breath due to exertion, excess mucus, or a respiratory infection. Patients like these are susceptible to acute illness and need careful monitoring.
What does it mean when a respiratory rate is too fast?
A respiratory rate greater than 20 while resting is not normal in older adults. This means that there is some stress. Here are some possible causes:
- Some people who are chronically ill or weak have a respiratory rate which is faster than normal. For instance, a patient who has severe heart or lung disease may always have a fast respiratory rate. Patients like these have a chronic shortness of breath.
- Emotional stress, being anxious or excited
- Worsening COPD or asthma
- Worsening heart failure
- A respiratory infection such as a pneumonia, a “cold”, bronchitis, flu or COVID
- An acute illness that is stressing the body and resulting in fast breathing. This could be something like a urine infection or uncontrolled diabetes.
What does it mean when a respiratory rate is too slow?
A resting respiratory rate less than 14 when a senior is awake is not normal. The brain automatically stimulates breathing. Breathing that is too slow means that the brain is not working correctly. Here are some potential causes:
- The most common cause is over sedation. This can be due to narcotics, sleeping pills, or alcohol. Medications that effect the emotions can also result in sedation.
- Sleep disorders such as Sleep Apnea
- Excess use of oxygen, especially in patients with severe COPD. Oxygen can suppress the breathing reflex.
- A brain injury such as a stroke.
- A severe illness. The illness is so severe that the brain is not working normally.
A respiratory rate that is not normal for that person is an important finding. When the respiratory rate is persistently too fast or too slow, check all the vital signs. A diabetic patient should have the blood sugar checked. Contact a health care professional. Be sure to have a complete list of all medications.
Do I need a Pulse Oximeter?
A pulse oximeter is a clip device that is placed on the finger. It measures the amount of oxygen in the blood. Pulse oximeters have become widely used and less expensive in the past decade. They are easy to use but occasionally inaccurate. Some patients have severe heart or lung disease or sleep apnea. They benefit from having a pulse oximeter. For most other patients, a pulse oximeter is optional.
The pulse oximeter produces a number called the oxygen saturation. An oxygen saturation level of 95% or higher is normal. A lower number means that the amount of oxygen carried in the blood is less than what the body needs. Some people with severe heart or lung disease always have low oxygen saturation.
For most people, an oxygen saturation level of less than 95% is worrisome. It can mean that heart or lung disease has become worse. In patients with COPD or asthma, extra attention to clearing the airway is important. An inhaler or nebulizer treatment can help. A low oxygen saturation can also mean an acute respiratory infection such as a pneumonia. An oxygen saturation of less than 95% in an older person who has COVID-19 is a cause for concern.
Is it important to check the respiratory rate when oxygen saturation is normal?
A respiratory rate and pulse oximetry both provide information about the respiratory system. But the information provided is different. A person can have normal oxygen saturation but a fast respiratory rate. This is still an important problem. It means that the lungs are working extra hard to provide enough oxygen.
When does a patient need oxygen?
People who are acutely ill and short of breath feel better when given oxygen. Many patients in the Emergency Room or hospital are given oxygen. But long-term use of oxygen is seldom indicated. The use of oxygen can help a patient feel better. But in the long term, too much oxygen can injure the lungs.
Hypercapnia and COPD
An uncommon severe problem
Some patients with severe COPD qualify for home oxygen. The oxygen relieves shortness of breath and helps a person feel better. But too much oxygen can cause acute hypercapnia. The patient with COPD may have abnormal breathing mechanisms. The body senses enough oxygen and breathing slows down. The respirations become too slow and often shallow. This results in a buildup of too much carbon dioxide in the body. The result is sedation and confusion or other even more serious neurologic problems. The risk is especially high in COPD patients who take sedatives, alcohol, or narcotics. People who use oxygen need to be well instructed. Oxygen is a powerful treatment that can do harm.
PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.