12. Managing breathing difficulty – July 2015
When managing the patient with breathing difficulty there are key actions to do and key actions to not do. These include positioning the patient, maintaining effective ventilation and avoiding causing any exertion.
The first key thing to work out is if the patient is having difficulty breathing or whether the breathing has begun to fail. The patient in breathing failure is not able to move enough air in and out of the lungs to support even the most basic functions. This patient may be slumped, not talking, or indeed, not making any conscious responses at all. There isn’t enough oxygen being drawn into the blood or carbon dioxide being removed to allow the brain to function properly.
Management of the two situations is very different. For the patient in breathing failure, it is critical to assist the breathing. Using a device such as a bag/valve/mask, high concentration oxygen is provided through a mask sealed against the patient’s face. Simple oxygen administration won’t be enough though. The bag of the device will have to be intermittently squeezed to ensure that some oxygen is actually pushed down into the lungs. Remember the patient is in breathing failure and is not able to draw the air in by themselves.
Every patient must be managed in some position. This position for the patient in breathing failure will be one that allows the bag/valve/mask to be used. The patient may be unconscious and managed either supine or in the lateral position. The lateral position might turn out to be more difficult for many rescuers.
For the patient who is still awake and in breathing difficulty, most will be managed sitting up. Sitting up allows the arms to help drag the lungs open. This is particularly so for asthma and chronic lung diseases. Most patient’s having trouble breathing will want to sit upright if they are able. Others rest in bed propped on multiple pillows which is commonly how chest infection and APO present. Some may become quite agitated if it is tried to place them otherwise.
Oxygen therapy should be commenced usually using an oxygen mask with 8 litres per minute for most patients. This flow rate will also support using a nebuliser mask. If the bag/valve/mask is being used the oxygen hose can be attached to it.
In some cases a nasal cannula can be used at a lower flow rate of 2 – 3 litres per minute. This might be the preferred option for patients who have only mild breathing difficulties. It might also be the preferred option for people who have chronic lung diseases such as emphysema and bronchitis
Where there is wheezing or a diagnosed history of asthma, the patient with breathing difficulty may be administered salbutamol. This drug is often taken by the patient before any call for help using a puffer or a mask. It can be administered by first responders using a nebulising mask. It is important to remember that if the patient’s own breathing cannot supply enough air to the lungs to keep the brain fully functioning then it also cannot supply any drugs via a nebuliser.
Occasionally, breathing difficulty may be caused by airway obstruction. This may be a foreign body such as half chewed food or gastric content regurgitated back up. In such cases, encouraging coughing, providing back slaps or chest thrusts may help clear the obstruction. Other obstructions can be caused by poor head position or the tongue falling back onto the posterior airway. Airway obstruction may be caused by the loss of consciousness that results from breathing difficulty or it may be the cause of the breathing difficulty. Whatever the airway problem, it must be recognised and managed.
All patients with breathing difficulty have the potential to deteriorate. Problems that cause breathing difficulty should always be thought of as having potential to get worse. Prolonged pre-hospital times should be avoided in all cases.
Where the patient does deteriorate, whatever treatment is being provided has proven to be not enough. The level of response must be increased as a result. This may mean moving from oxygen mask to using a bag/valve/mask to assist breathing. If the patient loses their pulse they should be managed as if they are in cardiac arrest
The patient with severe breathing difficulty can only take in minimal oxygen and remove minimal carbon dioxide. Any increase in oxygen consumption and carbon dioxide production will not be able to be compensated for. Even minimal exertion may prove life threatening for some patients. Administering oxygen therapy to a patient with breathing difficulty increases oxygen supply. By having the patient rest and move as little as possible, the demand for oxygen is reduced.
Do not ask the patient with breathing difficulty to walk, slide themselves across a bed or, in severe cases, even stand up and sit down again. Some patients with breathing difficulty may not even be able to manage these simple actions without serious deterioration.
Before moving any patient, question them as to how they have been moving around recently and what difficulty that posed. If any physical exertion is considered a risk to the patient then manual handling methods of patient transfer must be considered including use of slide sheets, wheelchairs and walk lift belts all typically available in ambulances.
Jeff Kenneally www.prehemt.com
Jeff is the author of the 2014 – 2016 Ambulance Victoria First Responder clinical practice protocols and accompanying education program.