10. Respiratory assessment for first responders – July 2015
The respiratory system is capable of very different presentations. The difference between resting breathing that caters only for basic body needs and the great increase needed for light and heavy exercise is considerable. Changes in breathing rate and depth are observed.
Not all changes in presentation are for normal or expected needs. Changes in breathing can also be in response to a problem. These might be introduced, such as an airway obstruction, medical cause such as asthma or trauma such as rib fractures. The severity of the impact of these can be assessed using the respiratory status assessment.
The subjective measure of breathing difficulty is to simply look at the patient and estimate how sick they appear. This can be hugely influenced by past experience or a range of judgemental perceptions. An objective alternative way to assess breathing is to use some form of respiratory status assessment (RSA). Such a tool looks at a number of features of breathing that can be both measured and evaluated. It then compares what should be normal findings to whatever is found to be abnormal. The RSA is a core component of vital sign assessment for every patient.
The key components of assessing respiration for the first responder are:
Respiratory rate: Respiratory rate is simply the number of breaths the patient takes in one minute. Typically, like counting the pulse, you can count breaths over a shorter time and multiplying it to equal one minute. This rate should normally be between 12 to 16 per minute with notably faster (above 20) or slower (less than 8) rates indicating a problem. Faster frequently suggests the body is trying to respond to some form of problem. Slower is abnormal and suggests some interference with the drive to breath. A normal rate of breathing is necessary to ensure sufficient oxygen is taken in. More importantly though, the right amount of waste carbon dioxide must be removed.
Respiratory rhythm: This should be regular with evenly spaced breaths. Inspiration should be slightly shorter than expiration with a short pauses between each. Expiration takes a little longer because it is mostly through passive relaxation. Expiration may become abnormally long in asthma and the regular pattern of breathing may be lost in stroke or head injury
Effort of breathing: This may be the most visible clue in breathing assessment. Normal effort breathing is barely noticeable. You usually have to pay attention to notice a person’s breathing. Patients with breathing difficulty may lean forward to breathe trying to use the upper chest and arms to open up all of the lungs for breathing. Frequently they brace themselves with the two outstretched arms against a benchtop and the legs in the middle forming a so called ‘tripod’ appearance. The muscles of breathing may be working harder than usual and appear to be ‘sucked’ into the chest with each breath. In children this will be most noticeable with the diaphragm even appearing to disappear under the ribs.
Patient appearance: The patient in respiratory distress is usually noticeable. Difficulty breathing easily causes panic with many patients becoming anxious and agitated. Even mildly distressed patients can be unrelaxed and concerned. Not being able to breathe properly is likely to be a terrible feeling for most people.
Ability to speak: Speech relies on the ability to inhale air then exhale it slowly to produce words. If air entry is reduced or the need to draw in another breath interrupts the ability to speak then this will interfere with the ability to speak. A full sentence should be able to be spoken. In respiratory distress this may be shortened to a short sentence followed immediately by the next breath. In severe distress this may be shortened to words only or even an inability to speak. The fewer words, the sicker the patient. In such cases, try not to ask questions of the patient that take a lot of words to answer,
Respiratory noises: Normal breathing is quiet. Abnormal noise not only suggests breathing difficulty but may provide clues to the cause of the problem. Noises include stridor, snoring, wheezing, crackles or coughing. These noises may be heard by standing near to the patient or they may need a stethoscope to hear properly. The different noises are formed by a variety of different problems. The actual noise is a strong clue as to what the problem is and where it is in the respiratory system.
Coughing may be dry or may be accompanied by sputum production. It may have the barking sound of croup. Stridor is an upper airway noise heard on inhalation. It is similar to wheezing being caused by air moving through a narrowed airway only this time the upper part. Wheezing is a whistling noise caused by air having trouble moving through the smallest airways. Crackles can be fine like crinkling foil paper or course and syrupy. Generally they are caused by either fluid or infection finding its way into the alveoli.
Snoring is caused by the tongue and relaxed muscles of the soft palate in the mouth creating an obstruction in the upper airway and is corrected by upper airway strategies such as head tilt or even inserting an oropharyngeal airway device. Wheezing and crackles are discussed later with lower airway problems.
Though breathing is quiet, it is not silent. If no breathing can be heard with a stethoscope it means that air movement is so reduced the patient is in severe difficulty. Not being able to hear breathing is like not being able to feel a pulse – not good.
Patients in respiratory distress may be pale and clammy, red and flushed or may have blueness on the lips, ears and fingers. This depends on underlying cause.
Patients are said to have either a normal respiratory status or to have some respiratory distress (breathing difficulty). In practice the observer may be able to finely distinguish between mild breathing difficulty and more severe cases but this is not essential for first responders. It is sufficient to say that the patient is either having trouble breathing or they are not. Clearly patients who are in severe distress will have more noticeable changes in the RSA variables. Those in severe respiratory distress are obviously in great difficulty however even mild respiratory distress is important.
When assessing any patient with breathing difficulty it is important to assess for evidence of breathing difficulty using the RSA. It is also important to assess a patient who states that they feel breathless, short of breath or feel that they are having trouble breathing. These are all features that the patient complains of. That is, they are symptoms. The features of the RSA are signs. Patients should not normally feel breathless so this complaint is always important. However simply complaining of breathing difficulty does not mean that the patient will actually appear to be having trouble breathing.
History is a key part of assessment looking for what is happening on this occasion and any past problems they may have had with their breathing.
To assess the patient with breathing difficulty, the chest needs to be exposed to some extent. The muscles of the chest need to be seen and the skin of the front and back reached if a stethoscope is going to be used.
Jeff Kenneally www.prehemt.com
Jeff is the author of the 2014 – 2016 Ambulance Victoria First Responder clinical practice protocols and accompanying education program.