As an EMT, you will often encounter the patient complaint of dyspnea, when a patient reports shortness of breath or has difficulty breathing. Abnormal or pathologic conditions in the anatomy of the airway, disease processes, and traumatic conditions can prevent the proper exchange of oxygen and carbon dioxide. Pulmonary blood vessels may have abnormalities that interfere with blood flow. Signs of breathing are measured by rate, rhythm, and quality. A normal rate is between 12 and 20 breaths in adults, 15 to 30 in a child, and 30 to 60 in an infant, with a regular breathing pattern, clear and equal breath sounds on both sides of the chest, regular and equal chest rise and fall, and adequate depth without labored sounds such as wheezing or stridor.
Signs of inadequate breathing include patient reports of difficulty breathing; altered mental status associated with shallow or slow breathing; anxious or restless behavior in adults; sleepy or listless behavior in children; respiratory rate that is too fast or too slow; irregular rhythm; pale, cool, clammy, or cyanotic skin; adventitious breath sounds including wheezing, gurgling, snoring, crowing, or stridor; decreased or noisy breath sounds heard on one or both sides of the chest; inability to speak more than a few words; accessory muscle use; retractions or labored breathing; unequal or inadequate chest expansion; coughing; tripod position; pursed lips; or nasal flaring.
The upper airway consists of all the structures above the level of the vocal cords. These include the nose, mouth, jaw, oral cavity, pharynx, and larynx. The upper airway ends at the larynx, which is protected by the epiglottis, which diverts food and fluid into the esophagus. It also allows air to flow freely between the vocal cords into and out of the trachea. To reach the lower airways, air travels through the trachea into each lung, first passing through the left and right mainstem bronchi (larger airways), then into the bronchioles (smaller airways), and finally into the alveoli, which exchange oxygen and carbon dioxide.
There are several different types of respiratory system illnesses and terms. Asthma is mainly associated with wheezing and can be treated with an inhaler. It is an acute spasm of the bronchioles associated with excessive mucus production and swelling of the mucous lining of the respiratory passages, causing partial lower airway obstruction.
Hay fever (allergic rhinitis) causes cold-like symptoms including runny nose, sneezing, congestion, and sinus pressure. Symptoms are caused by an allergic response. People with hay fever tend to be atopic and at risk for anaphylaxis. An anaphylactic reaction is a shock state characterized by a severe allergic reaction with airway swelling. It may be associated with urticaria (widespread hives) and signs and symptoms similar to asthma. The airway may swell so much that breathing problems can progress to total airway obstruction in a matter of minutes. For some patients, this may be the first episode of anaphylaxis, and they may not know what caused the reaction. Treatment includes epinephrine (adrenaline), oxygen, and antihistamines.
Croup is caused by inflammation and swelling of the pharynx, larynx, and trachea, secondary to an acute viral infection seen in children between 6 months and 3 years of age. The hallmark signs of croup are stridor and a seal-bark cough. It responds well to humidified oxygen. Bronchodilators are not indicated for croup and can worsen a patient’s symptoms.
Epiglottitis is a life-threatening inflammatory disease of the epiglottis, the small flap of tissue at the back of the throat that protects the larynx and trachea. It is a bacterial infection mostly seen in children, though the Haemophilus influenzae vaccine has greatly reduced its incidence. Signs include a very sore throat and high fever; patients are often found in the tripod position and drooling. Stridor is a late sign. Treat with high-flow oxygen and do not put anything in their mouth.
Respiratory Syncytial Virus (RSV) is an illness in young children and is an infection of the lungs and breathing passages that can lead to bronchiolitis and pneumonia. RSV is highly contagious and spreads through droplets when the patient coughs or sneezes. The virus can also survive on surfaces, including hands and clothing. Look for dehydration and refusal of liquids, and treat with humidified oxygen.
Bronchiolitis is a respiratory illness that often occurs due to RSV infection and results in severe inflammation of the bronchioles. Bronchioles are tiny airways that lead from the larger airways (bronchi) to the alveoli and can become inflamed, swollen, and filled with mucus. It is most common in newborns and toddlers and occurs most often during winter and spring. Provide oxygen therapy and suction thick mucus from the nostrils if present.
Pneumonia is an infection that collects in the surrounding normal lung tissues, impairing the lung’s ability to exchange oxygen and carbon dioxide, and is often a secondary infection. Patients predisposed to pneumonia include those with institutional residence, recent hospitalization, chronic disease processes (such as renal failure requiring dialysis), immune system compromise, and a history of COPD. Signs include labored breathing (grunting or wheezing sounds), febrile seizures, decreased skin turgor, exertional dyspnea, productive cough, chest discomfort or pain, headache, nausea and vomiting, musculoskeletal pain, weight loss, and confusion. Treatment includes airway support and supplemental oxygen.
Pertussis, also known as whooping cough, is an airborne bacterial infection that mainly affects children younger than 6 years and is highly contagious through droplet infection. Signs include fever and a “whoop” sound on inspiration after a coughing attack. Coughing spells can last more than a minute and may cause vomiting and decreased desire to eat or drink, so watch for signs of dehydration. You may need to suction thick secretions to clear the airway.
Influenza Type A, like seasonal flu, causes fever, cough, and sore throat and may lead to pneumonia. COVID-19 presents with similar symptoms, and respiratory deterioration in these patients can be dramatic and rapid.
Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis. It spreads by coughing and is dangerous because many strains are resistant to antibiotics. TB most commonly affects the lungs but can be found in almost any organ of the body. TB can remain dormant for years without causing symptoms or being infectious. Symptoms include fever, cough, fatigue, night sweats, and weight loss. If lung infection becomes severe, the patient may experience shortness of breath, productive cough, bloody sputum, and chest pain. As an EMT, you are at risk.
Acute pulmonary edema occurs when, often after a heart attack or other illness, the left side of the heart cannot remove blood from the lungs as fast as the right side delivers it. As a result, fluid builds up within the alveoli and lung tissue between the alveoli and pulmonary capillaries, causing pulmonary edema, usually due to congestive heart failure. This interferes with oxygen and carbon dioxide exchange. High blood pressure and low cardiac output can trigger sudden “flash” pulmonary edema. Frothy pink sputum may be seen at the nose and mouth. Predisposing factors include congestive heart failure, hypertension, coronary artery disease, and atrial fibrillation. Smoke inhalation or toxic chemical fumes can also cause this condition. Patients may report sudden coughing attacks, feeling suffocated, cold sweats, and tachycardia. You may find cool, diaphoretic, cyanotic skin and hear adventitious breath sounds.
Chronic Obstructive Pulmonary Disease (COPD) is a chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible. It includes diseases such as emphysema and chronic bronchitis, which involve ongoing irritation of the trachea and bronchi. It may result from repeated infections or inhalation of toxic gases and particles, but most often from cigarette smoking. Smoking greatly increases the risk of both COPD and lung cancer.
Emphysema involves loss of elastic tissue in the lungs, causing chronically stretched alveoli and large air pockets. There is little cough or mucus, dry lung sounds, and pink skin.
Chronic bronchitis involves excessive mucus production, chronic cough, wet lung sounds, and blue skin. Most COPD patients chronically produce sputum, have difficulty expelling air, and present with crackles, rhonchi, or wheezes. CHF patients often have wet lung sounds, while COPD patients often have dry lung sounds, though overlap is common.
Spontaneous pneumothorax is the partial or complete accumulation of air in the pleural space. It is often caused by trauma but can also result from medical conditions or rupture of a weakened lung area during severe coughing. Patients may report pleuritic chest pain—sharp, stabbing pain on one side that worsens with inspiration, expiration, or chest wall movement. Continually reassess for anxiety, increased dyspnea, hypotension, absent or severely decreased breath sounds on one side, jugular vein distension, and cyanosis.
Pleural effusion is a collection of fluid outside the lung on one or both sides of the chest. It compresses the lung and causes dyspnea. Fluid may collect in response to infection, congestive heart failure, or cancer. You will hear decreased breath sounds over the affected area.
Pulmonary embolism occurs when blood flow is obstructed, most often by a clot that forms in a vein, breaks loose, travels through the right side of the heart, and lodges in the pulmonary artery. This can be life-threatening. Though uncommon, pulmonary emboli can occur in otherwise healthy individuals, but they are more common in patients with cancer or prolonged bed rest. Symptoms include dyspnea, tachycardia, tachypnea, hypoxia, cyanosis, acute chest pain, and hemoptysis.
When approaching a patient, always ensure the scene is safe before beginning the primary exam. Focus on XABC. Ensure the airway is not blocked, then focus on breathing. Check responsiveness using the AVPU scale. If the patient responds, they have an airway. Assess whether air flows in and out of the chest easily, evaluate respiratory rate, rhythm, and quality, look for accessory muscle use, retractions, depth, tidal volume, chest rise and fall, and skin color, temperature, and moisture. If breathing is labored, place the patient in full or semi-Fowler’s position and administer oxygen at 15 L/min via nonrebreather mask. If breathing is inadequate, assist ventilations with a bag-mask device.
Assess both sides of the chest and complete a full respiratory cycle at each location. Pay special attention to lower lung fields when assessing for fluid. Start from the bottom. Clear airflow should be heard bilaterally.
- Wheezing: asthma, COPD, CHF/pulmonary edema, pneumonia, bronchitis, anaphylaxis
- Rhonchi: COPD, pneumonia, bronchitis
- Crackles: CHF/pulmonary edema, pneumonia
- Stridor: croup, epiglottitis
Some common medications include:
- Albuterol (Proventil) – bronchodilator; asthma, bronchitis, COPD (acute)
- Beclomethasone (Beclovent) – anti-inflammatory; asthma (chronic)
- Cromolyn (Intal) – decreases histamine release; asthma (chronic)
- Fluticasone (Flovent Diskus) – anti-inflammatory; asthma (chronic)
- Fluticasone/salmeterol (Advair Diskus) – decreases secretions; asthma (chronic)
- Ipratropium bromide (Atrovent) – bronchodilator; asthma, bronchitis, COPD (acute)
- Levalbuterol (Xopenex) – bronchodilator; asthma, bronchitis, COPD (acute)
- Metaproterenol (Alupent, Metaprel) – bronchodilator; asthma, bronchitis, COPD (acute)
- Montelukast (Singulair) – anti-inflammatory; asthma, COPD (chronic)
- Salmeterol (Serevent Diskus) – bronchodilator; asthma, bronchitis, COPD (chronic)
Contraindications for MDI use include:
- Patient cannot coordinate inhalation with activation
- Medication not prescribed for the patient
- No medical control authorization
- Maximum dose already taken
- Medication is expired
- Other medication-specific contraindications
Leave a Reply