What is the minimum acceptable respiratory rate in a normal adolescent?

A breathing or respiratory rate is a measure of the number of full breaths taken in one minute. Full breaths are measured as the completion of one inhalation and exhalation cycle. Several factors impact breathing rates including exertion, lung capacity and overall respiratory health. Respiratory rates are also affected by age, and the normal range for a teenager is distinct from normal ranges of younger children and older adults. Understanding the scope of a normal respiration for adolescents is critical for quickly identifying abnormal breathing that may be a sign of a significant medical problem.

A normal respiration rate is measured at rest. Since respiration can be affected by physical activity or stress, assessing the number of breaths while a person is in a calm, relaxed, still state is essential for an accurate assessment of a typical, normal rate. For adolescents aged 12 to 18, normal respiration rates range from 12 to 20 breaths per minute. A 2011 study published in "The Lancet" evaluated 69 studies that measured respiratory rates in children and teens in order to determine more accurate percentiles and ranges for normal respiration. The researchers' findings suggest a wider range of normal rates for teenagers, with a lower limit of 10 breaths per minute and an upper limit of 25 breaths per minute. Their study illuminates a broader range of normal breathing rates as well as the variability among measuring techniques.

Respiratory rates gradually decrease as people age. As lung capacity expands, breathing becomes more efficient and fewer breaths per minute are required for oxygen transfer. The lungs also develop more alveoli, the structures responsible for transferring oxygen in the lungs to blood vessels that deliver it to tissues throughout the body. Infant breathing rates can be as high as 60 breaths per minute, while an adult may breathe as infrequently as 10 times per minute. Adolescents can also be expected to show a decrease in breathing rates as they move through puberty. For example, a teenager who breathes 16 times per minute at age 13 may breathe just 13 times per minute by age 18.

Strategies for accurately measuring respiration vary. The American Academy of Pediatrics notes that respiration typically transfers from primarily located in the abdomen in infancy to primarily located in the upper chest muscles by adolescence. While counting the number of times the abdomen rises and falls in one minute may be a useful strategy for infants, practitioners should measure the rises and falls of the upper chest in adolescents, and the movement may be much less pronounced and therefore difficult to assess. Another consideration is that knowledge of the measurement may impact normal breathing, so counting breaths while the subject is unaware is also a strategy. To determine a respiratory rate of a teenager, count the number of full breaths that occur in 30 seconds. Multiply the number by two for the number of breaths per minute.

Respiration rates may be outside the normal respiration ranges without indicating a problem. For example, a teenager may breathe more slowly during deep relaxation or more quickly during exercise. A respiratory rate at rest that is above the normal range for a teenager may indicate a respiratory infection or increased anxiety; lower than normal respiration at rest is typically indicative of an illness of the central nervous system. Respiratory ailments are typically assessed through other problems with breathing, such as shallow breathing, labored breathing or pain or difficulty during breathing. Any signs of respiratory distress should be immediately assessed and treated by a medical professional.

During evaluation, conduct the primary assessment, secondary assessment, and diagnostic tests. If at any time a condition is determined to be life-threatening, intervene immediately.

Primary Assessment

Assessment	Assessment Techniques	Abnormal Findings	Interventions
A – Airway	Observe for movement of the chest or abdomen; Listen to the chest for breath sounds	Obstructed but maintainable	Keep airway open by head tilt/chin lift
Obstructed and cannot be opened with simple interventions	Keep airway open using advanced interventions
B – Breathing	Rate	<10 or >60 = Abnormal (apnea, bradypnea, tachypnea)	Immediate respiratory intervention required
Effort	Nasal flaring, head bobbing, seesaw respirations, retractions	Immediate respiratory intervention required
Chest or abdominal expansion	Asymmetrical or no chest movement	Immediate respiratory intervention required
Breath sounds	Stridor, grunting, wheezing, rales, rhonchi	Immediate respiratory intervention required
Oxygen saturation (O2 sat)	<94% on room air <90% at any time	Supplemental oxygen Advanced airway
C – Circulation	Heart rate	Bradycardia	Bradycardia Algorithm
Tachycardia	Tachycardia Algorithm
Absent	Cardiac Arrest Algorithm
Peripheral pulses (radial, posterior tibial, dorsalis pedis)	Diminished or absent	Close monitoring
Central pulses (femoral, brachial, carotid, and axillary)	Diminished or absent	Management of Pediatric Shock
Capillary refill	>2 seconds	Management of Pediatric Shock
Skin color/temperature	Pale mucous membranes	Management of Pediatric Shock
Central cyanosis	Immediate respiratory intervention required
Peripheral cyanosis	Management of Pediatric Shock
Blood pressure	Outside normal range for age	Management of Pediatric Shock
D – Disability	AVPU Scale	Alert – Awake, active, responsive to parents (normal) Uoice – Responds only to voice Pain – Responds only to pain Unresponsive – Not responsive	Monitor and consult neurologist
Glasgow Coma Scale	Pediatric Glasgow Coma Scale
Pupils	Unequal or non-reactive
E – Exposure	General evaluation	Signs of bleeding, burns, trauma, petechiae, and purpura	Management of Pediatric Shock

Table 3: Primary Assessment Model

Use the Primary Assessment to evaluate the child using vital signs and an ABCDE model:

A – Airway

Head tilt-chin lift and jaw thrust may be used to open the airway quickly and without the use of an advanced airway. The jaw thrust maneuver is preferred when a cervical spine injury is suspected or cannot be ruled out.

Advanced interventions for maintaining a patent airway may include:

Laryngeal mask airway (LMA)
Endotracheal (ET) intubation
Continuous positive airway pressure (CPAP)
Foreign body removal if one can be visualized
Cricothyrotomy in which a surgical opening is made into the trachea.

B – Breathing

The child’s respiratory rate is an important assessment that should be made early in the primary assessment process. The clinician must be aware of normal respiratory ranges by age:

Age Category	Age Range	Normal Respiratory Rate
Infant	0-12 months	30-60 per minute
Toddler	1-3 years	24-40 per minute
Preschooler	4-5 years	22-34 per minute
School age	6-12 years	18-30 per minute
Adolescent	13-18 years	12-16 per minute

Table 4: Normal Respiratory Rates

A respiratory rate that is consistently below 10 or above 60 breaths per minute indicates a problem that needs immediate attention. Periodic breathing is not unusual in infants; therefore, you may have to spend more time observing the infant’s breathing to determine true bradypnea or tachypnea. Nasal flaring and retractions indicate increased work of breathing. Head bobbling or seesaw respirations are potential signs of impending deterioration. Likewise, slow and/or irregular breathing suggest imminent respiratory arrest.

C – Circulation

The child’s heart rate is another important assessment that should be made in the primary assessment. The normal heart rates by age are:

Age Category	Age Range	Normal Heart Rate
Newborn	0-3 months	80-205 per minute
Infant/young child	4 months to 2 years	75-190 per minute
Child/school age	2-10 years	60-140 per minute
Older child/ adolescent	Over 10 years	50-100 per minute

Table 5: Normal Heart Rates

The child’s blood pressure should be another part of the primary assessment. Normal blood pressures by age range are:

Age Category	Age Range	Systolic Blood Pressure	Diastolic Blood Pressure	Abnormally Low
Systolic Pressure	1 Day	60-76	30-45	<60
Neonate	4 Days	67-84	35-53	<60
Infant	To 1 month	73-94	36-56	<70
Infant	1-3 months	78-103	44-65	<70
Infant	4-6 months	82-105	46-68	<70
Infant	7-12 months	67-104	20-60	<70 + (age in years x 2)
Preschool	2-6 years	70-106	25-65	<70 + (age in years x 2)
School Age	7-14 years	79-115	38-78	<70 + (age in years x 2)
Adolescent	15-18 years	93-131	45-85	<90

Table 6: Normal Blood Pressure

D – Disability

One of the assessments of level of consciousness in a child is the Pediatric Glasgow Coma Scale (GCS).

Response	Score	Verbal Child	Pre-Verbal Child
Eye opening	4 3 2 1	Spontaneously To verbal command To pain None	Spontaneously To speech To pain None
Verbal response	5 4 3 2 1	Oriented and talking Confused but talking Inappropriate words Sounds only None	Cooing and babbling Crying and irritable Crying with pain only Moaning with pain only None
Motor response	6 5 4 3 2 1	Obeys commands Localizes with pain Flexion and withdrawal Abnormal flexion Abnormal extension None	Spontaneous movement Withdraws when touched Withdraws with pain Abnormal flexion Abnormal extension None
Total Possible Score	3-15

Table 7: Pediatric Glasgow Coma Scale

When there is a suspected or known head injury, a GCS score of 13 to 15 is considered mild, 9 to 12 is moderate, and 3 to 8 is severe. In intubated or sedated children, motor response provides the most important information. The lower the motor response score, the more serious the deficit/injury.

E – Exposure

If the provider finds any abnormal symptoms in this category they should assess and treat the child for shock (see Unit Seven: Management of Pediatric Shock, particularly Interventions for Initial Management of Shock). During the primary assessment, if the child is stable and does not have a potentially life-threatening problem, continue with the secondary assessment.