Recognising Increased Work of Breathing for Student Nurses
Learn how to recognise when a patient is working harder to breathe, assess respiratory effort systematically and identify signs that may indicate developing respiratory distress.
What is increased work of breathing?
Increased work of breathing describes the additional physical effort a patient needs to make to ventilate effectively. It may be visible before dramatic changes occur in oxygen saturation or other observations.
Breathing faster
Respiratory rate may increase as the patient attempts to meet greater respiratory demand.
Breathing harder
Neck, shoulder or chest muscles may become increasingly involved in breathing.
Breathing affects speech
A breathless patient may struggle to speak comfortably in complete sentences.
Signs of increased respiratory effort
Neck and shoulders
Muscles around the neck, shoulders or upper chest may become more visibly involved with each breath.
Recession or indrawing
Look for abnormal inward movement around the ribs or other visible signs of increased respiratory effort.
Postural changes
A breathless patient may sit upright or adopt a position that helps them breathe more comfortably.
Difficulty speaking
The patient may pause frequently or only manage short phrases between breaths.
Distress
Anxiety, agitation, sweating or visible exhaustion may accompany respiratory difficulty.
Abnormal breathing noises
Audible wheeze, stridor or other unusual respiratory sounds may indicate an important airway or breathing problem.
How should you assess breathing effort?
Observe before touching
Look at the patient's position, chest movement, colour and apparent respiratory effort.
Count respiratory rate
Measure the respiratory rate accurately and compare it with previous observations.
Assess depth and pattern
Observe whether breathing is shallow, deep, irregular or otherwise different from before.
Assess oxygenation
Review oxygen saturation, prescribed target range and whether oxygen requirements have increased.
Assess speech
Listen to whether the patient can speak normally or needs to pause frequently for breath.
Complete the wider ABCDE picture
Review circulation, consciousness and other observations to identify broader deterioration.
Observe before the monitor
A monitor provides useful measurements, but it cannot show you everything. The patient's posture, speech, facial expression and breathing effort can provide vital clinical information.
Connect respiratory effort with other findings
| Finding | What you may notice | Why it matters |
|---|---|---|
| Tachypnoea | Respiratory rate is increasing. | Faster breathing may accompany increasing respiratory demand. |
| Falling SpO₂ | Oxygen saturation falls or oxygen requirement increases. | This may indicate worsening oxygenation. |
| Difficulty speaking | Speech becomes fragmented by breathlessness. | This can provide a simple indication of significant respiratory difficulty. |
| Accessory muscle use | Neck, shoulder or chest muscles visibly assist breathing. | Additional muscle recruitment suggests increased respiratory effort. |
| Agitation | The patient becomes restless, anxious or unusually distressed. | Behavioural change can accompany hypoxia or respiratory distress. |
| Reduced consciousness | The patient becomes drowsy or less responsive. | This is a particularly concerning sign in a patient with respiratory difficulty. |
The patient can deteriorate before the saturation falls dramatically
A patient who is tachypnoeic, using accessory muscles and struggling to speak may already be significantly unwell even if their oxygen saturation initially appears relatively preserved.
When increased effort starts to decrease
One of the most important patterns for a student nurse to recognise is a patient who has been working extremely hard to breathe and then appears to become quieter.
High respiratory effort
Rapid breathing, accessory muscle use and obvious respiratory distress.
Patient becomes quieter
Breathing effort appears reduced, but the patient also looks tired or increasingly drowsy.
Possible exhaustion
Reduced respiratory effort may represent worsening respiratory failure rather than recovery.
Putting the findings together
Example
A patient tells you they are becoming increasingly breathless.
Their respiratory rate is 29 breaths per minute. They are sitting upright and visibly using their neck and shoulder muscles to breathe.
They can only speak a few words before pausing for breath, and their oxygen saturation has fallen compared with earlier observations.
The concern is the combined pattern of tachypnoea, increased respiratory effort, difficulty speaking and worsening oxygenation.
As a student nurse, recognise the deterioration, begin an appropriate ABCDE assessment within your competence and communicate the findings promptly to the appropriate registered practitioner.
Breathing assessment errors to avoid
- Looking only at oxygen saturation. Assess respiratory effort as well.
- Recording respiratory rate without observing breathing. Rate and effort provide different information.
- Ignoring the patient's speech. Difficulty speaking can indicate significant breathlessness.
- Assuming agitation is simply anxiety. Consider hypoxia and respiratory deterioration.
- Assuming a quieter patient is improving. Look for exhaustion and reduced consciousness.
- Waiting for severe desaturation before escalating. Clinical deterioration may already be evident.
Recognise → assess → communicate → escalate
Look at the effort
Notice accessory muscle use, altered posture, tachypnoea or difficulty speaking.
Build the breathing picture
Assess rate, depth, effort, oxygenation, speech and consciousness.
Describe what you see
Report both the numerical observations and visible signs of respiratory distress clearly.
Recognising Cyanosis for Student Nurses
Learn what cyanosis may look like, where to assess for colour changes and why suspected cyanosis must be interpreted alongside oxygenation, breathing and the patient's overall clinical condition.
Continue to Recognising Cyanosis →