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Before any physical examination, all patients should have their respiratory rate, effort, noise, and pattern observed from afar. If a patient is showing any changes in respiratory pattern or effort, oxygen supplementation should be provided immediately. If there is any respiratory compromise, the patient should be presumed to be in hypoxemic shock until proven otherwise and oxygen supplementation should be provided. Further respiratory triage involves auscultation of the upper airway, trachea, and thorax. During abbreviated thoracic auscultation, emphasis should be placed on determining heart rate, rhythm, the presence of murmur(s) or arrhythmia(s), and lung sounds in all lung fields. Visual and auditory assessment of respiratory pattern and noise combined with thoracic auscultation should help localize the anatomic origin of the respiratory distress. The impact of pain, stress, and anxiety on respiratory rate and effort should not be underestimated (Figure 1.1).

If respiratory noise is localized to the upper airway, diseases associated with an upper airway obstruction, including laryngeal paralysis, laryngeal collapse, brachycephalic airway disease, tracheal collapse, the presence of a tracheal, laryngeal, or pharyngeal mass, and the presence of a foreign body should be ruled out. See Chapter 28 for stabilization of the patient with upper airway obstruction.

Figure 1.1 Cat with open mouth breathing secondary to the pain associated with an aortic thromboembolism.

If decreased lung sounds relative to respiratory effort are heard dorsally, pneumothorax should be suspected. However, if decreased lung sounds are heard ventrally, pleural effusion should be considered. Lung sounds may not be completely absent in the presence of pleural effusion or pneumothorax, they may be reduced relative to the other lung fields but still present. See Chapter 34 for stabilization of the patient with pleural space disease. Diseases of the chest wall such as masses, rib fractures, and flail segments may also result in abnormal auscultation of the pulmonary parenchyma. For more information on chest wall disease, see Chapter 41.

For patients in respiratory distress with a heart murmur, arrhythmia, pleural effusion, or pulmonary crackles present on auscultation, cardiogenic and hypoxemic shock should be considered as possible differentials. This is particularly important since fluid therapy is often contraindicated in most patients with cardiac dysfunction or failure and must be ruled out, to the best of the clinician's ability on triage, prior to administering intravenous (IV) fluid therapy.