Vital Signs: Respirations

In the eyes of many EMTs, taking vital signs is BLS bread and butter. I’m not sure if I agree, since there’s other butter I’d hate losing more, but unquestionably vitals are something we do an awful lot of and probably ought be good at. Mainly, it’s the big three: pulse, pressure, and respiratory rate (the fourth vital sign is temperature, which is not considered vital prehospitally, and the de facto fifth sign is O2 saturation, which is not always available).

But woe unto the poor freshly-anointed Basic who enters the field and discovers that taking a blood pressure off his classmate at a quiet desk has almost nothing in common with playing hunt-the-Korotkoff on an elderly PVD patient in the back of a vehicle that sounds, to the layman, almost indistinguishable from a steam locomotive. With experience, we figure it out and we get by, but I’m always interested in the tricks that people have come to rely on, and here are some of my own. Let’s start with…



The man who said that any blind monkey can count respirations has never tried it on sick people.

The first challenge here is getting away with staring at someone’s chest without giving them the skeevs. Women may be a little more wary about this, but if you’re unsubtle enough even men may ask if you “like what you see.” One method is a classic: while taking a pulse, count your beats and then start counting respirations without looking away or dropping their wrist. It gives you an excuse to stare blankly, and the patient is rarely the wiser. Good multitaskers can even count a pulse while simultaneously counting respirations over the same interval of time, although this is a bit much for my own second-tier brain.

Alternately, you can place yourself out of the patient’s field of vision, a technique that girl-oglers will recognize. In the back of the rig, you can usually pull this off by simply moving behind the stretcher — the captain’s chair is often too far, blocking your vision unless the stretcher is very reclined, but moving to the end of the bench seat is usually far enough and more convenient anyway.

How about the shallow respirations that virtually can’t be seen? You can put a hand on their chest to feel, but this is a little weird in the conscious patient and again betrays your intentions. You’re better off maximizing your visibility. Make sure there are no piles of blankets or folds of clothing in the way, and try watching both the abdomen and the thorax, as different people breathe in different fashions. If you’re still having no luck, auscultate! Place your stethoscope and count from the lung sounds. In fact, respiratory distress patients will sometimes produce wheezes or crackles that are audible from the bedside, allowing you to get a count with the naked ear.

Some texts recommend counting for at least 30 seconds; this is accurate, but feels like a geological epoch. Unless respirations are highly irregular, I count for 15. That does mean that your results will always be a multiple of 4, but here’s a way to improve it: count partial breaths as well. If you start with the chest “up” and 15 seconds later end on a “down,” call it a half stroke — so 4.5 x 4 would mean a respiratory rate of 18. You can get even fancier with quarter-strokes but that may be a little silly unless their rate is very slow.

A final note: “ehhh, looks normal” is not a valid method for counting respirations. There are times for estimation, but one hospital-based study showed that an overwhelming number of patients were documented at triage as breathing exactly 16 times a minute. A statistical miracle! In other words, you’re not as good at eyeballing as you think; take a few seconds and do your job.

For other Vital Signs posts, see: Pulse and Blood Pressure


  1. I’ll admit outright that I am notoriously bad at counting respirations. I usually use the stethoscope trick, because even watching chest rise/fall is difficult, especially if the patient is answering questions. I ask them to breathe normally and I count for 15 or 30 seconds.

    However, usually on scene all I care about is absent, slow, normal, fast, or really fast. Same for pulse: less than 1 a second, about 1 a second, less than 2 a second, 2 or more a second.

    Any patient you must know their respiratory status should be on waveform capnography. Granted, basics in most area will not have this quantitative measure. If they did, which would only take a 1-2 hour in-service, ventilatory and perfusion status are easily measured.

  2. Nothing more annoying than trying to count respirations when someone keeps asking them questions. Agreed that for an initial assessment all you need as a general sense of adequacy, but I think part of the problem is that everyone thinks they’re better at guesstimating than they are… 16 and 24 can look awfully similar, but the difference can be clinically significant.

    BLS capnography would be magical, I’m always jealous when I see the medics who don’t have to count nuthin’. But most Basics wouldn’t know how to interpret it, unfortunately.

    • I admit that my initial assessment usually consists of “fast or slow, regular or irregular”. I typically count when I’m listening to lung sounds.

      • I got no problem with that Sean… initial assessment should be bam-bam-bam, normal or not. But at some point it’s good to count, especially if you’re documenting/reporting an actual number…

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