🧭 REBEL Rundown
















📌 Key Points



Short + shallow: Neuromuscular, bronchospasm, or compliance problem → act fast ⚠️Normal/large tidal volume: Compensation for metabolic/systemic causeUse all tools: 👁 Eyes: Chest rise, ✋ Hands: Palpate,👂 Ears: Listen, 🧠 Brain: Synthesize



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📝 Introduction



In this episode, we focus on the bedside evaluation of the tachypneic patient. Tachypnea (increased respiratory rate) can be an early indicator of serious illness, but not every tachypneic patient is on the verge of arrest. The key is honing your bedside assessment to recognize who is at risk for rapid deterioration and why. We break down a practical approach you can use immediately at the bedside.



🔑 Key Concepts



First Priorities at the Bedside



Chest Rise:Short, shallow respirations with poor chest rise are a major red flag.Patients with minimal tidal volumes are often approaching respiratory failure.Diaphoresis and Tachycardia:Diaphoresis + tachycardic patients with shallow breathing demand urgent attention as this is a sign of high catecholamine surge and impending respiratory collapse.Immediate Action:Use your eyes (chest rise), your ears (stethoscope), and brain (putting together all of the pieces together)



Short, Shallow Breathing: Think Three Major Buckets



Neuromuscular DiseaseMyasthenia gravis crisis, Guillain-Barré, myopathies, frailty.Weak inspiratory effort leads to low tidal volumes.Needs urgent positive pressure support (BiPAP, or intubation).Severe BronchospasmAsthma, COPD, anaphylaxis.Shallow, forced expirations signal airway obstruction.Silent Chest = airway emergency.Treat with bronchodilators, steroids, and positive pressure ventilation.Avoid immediate intubation if reversible; trial NIPPV first.Worsening Lung Compliance“Stiff lungs” harder to ventilate.Compliance (C) = Δ Volume / Δ PressureSo if it takes a lot of pressure to get adequate tidal volumes then your lungs are stiff and compliance is lowCauses include:Chest Wall: Rigidity, burn eschar.Pleural Space: Effusion, pneumothorax (check for asymmetric chest rise).Lung Parenchyma: Pneumonia, contusion, atelectasis.Below the Lung: Abdominal distension, ascites.Clinical pearl: Work outside-in (chest wall, pleura, lung, abdomen). 



Normal to High Tidal Volumes with Tachypnea: Systemic Causes




Metabolic Acidosis (e.g., DKA)Compensatory hyperventilation (Kussmaul breathing)Check a blood gas (VBG/ABG) to differentiate gap vs. non-gap acidosisRespiratory AlkalosisCauses: Pain, anxiety, fever, early sepsis, CNS issuesCentral drive increases respiratory rateAgain, ABG or VBG helps confirmDead Space VentilationPulmonary embolism (PE) is the classic cause.Other causes include:Severe emphysema: Alveolar walls are destroyed, so air reaches areas with no capillary blood flow.Pulmonary hypertension: High pressure damages and narrows vessels, reducing blood flow to ventilated alveoli.Low-flow states (shock): Poor systemic perfusion limits blood reaching alveoli, creating ventilated but under perfused areas.Excessive PEEP on ventilation: Overdistended alveoli compress nearby capillaries, blocking blood flow despite good ventilationKey concept: Easy to oxygenate, but tachypneic due to perfusion/ventilation mismatch. 




🛌 Practical Bedside Approach



Short, shallow breathing? Neuromuscular, bronchospasm, or compliance issueThink: Impending respiratory failure, act quickly.Normal to large tidal volumes? Systemic causesThink: Compensation (acidosis, pain, anxiety, PE).Use: Eyes (observe), Hands (palpate abdomen/chest), Ears (auscultate), Brain (synthesize).



🚨 Clinical Bottom Line



A careful, simple bedside assessment can rapidly identify which tachypneic patients need immediate intervention—and help you avoid missing those headed toward respiratory collapse. Stay sharp, stay systematic!













Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)



👤 Guest Contributors













Eric Acker, MD





Internal Medicine Resident, Rising Chief Resident,

Cape Fear Valley Medical Center,
Fayetteville NC










Micheal Bass DO





Internal Medicine Resident, Rising Chief Resident

Cape Fear Valley Medical Center,
Fayetteville NC










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