Characteristics of Normal Breathing

• A Normal Rate and Depth
• A Regular Patter of Inhalation & Exhalation
• Good Audible Breath Sounds Biaterally
• Regular rise and Fall Movement Bilaterally
• Pink, Warm, Dry Skin

• Breathing Rate Slower than 12 Breaths/min
• Breathing Rate Faster than 20 Breaths/min
• Unequal Chest Expansion
• Decreased Breath Sounds on 1 or Both Sides
• Muscle Retractions Above the Clavicles, Between the Ribs, and Below the Rib Cage
• Pale or Cyanotic Skin
• Cool, Damp, Clammy Skin
• Shallow or Irregular Respirations
• Pursed Lips
• Nasal Flaring

Causes of CO² Level Rise

• Lung Disease (Exhalation impairment)
• Body may produce too much CO²
• Chronic CO² Retention 

Disorders of the Lung

• Pulmonary veins and arteries are obstructed from absorbing oxygen or relaesing CO² by:
  • Fluid
  • Infection
  • Collapsed Air Spaces
  • Alveoli are damaged and cannot transport gasses properly across their own walls
• Air passages are obstructed by:
  • Muscle Spasms
  • Mucus
  • Weakened Floppy Airway Walls

• Blood flow to the lungs is obstructed by Blood Clots
• Pleural Space is filled with Air or Excess Fluid, so the Lungs cannot Properly Expand 
• Abnormalities in the pulmonary blood vessels

Causes of Dyspnea

Shortness of breath/difficulty Breathing

• Upper or Lower Airway Infection
• Accute Pulmonary Edema
• COPD
• Spontaneous pneumothorax
• Asthma
• Allergic Reactions
• Pleural Effusion
• Prolonged Siezures
• Obstruction of the Airway
• Pulmonary Embolism
• Hyperventilation
• Severe Pain (esp. chest)

Upper or Lower Airway Infection

• May effects all parts of the airway
• Problems is some form of instructions
• Exchange of gases between the alveoli and the capillaries

Acute Pulmonary Edema

One of the Most Common Causes of Hospitalization

• Heart muscle injury - heart muscle can't circulate blood properly
• Left side of the heart cannot deliver blood as fast as the Right Side delivers it
• Fluid builds up in the alveoli and lung tissue between the aveoli and the pulmonary capillaries
• Can develop quickly after a major heart attack

• Not enough room in the lung for slow deep Breathes
• Patients usually experiences:
  • Dsypnea
  • Rapid shallow respirations
  • Frothy pink sputum at the nose and mouth
• Usually long-standing history of CCHF

• Acute onset may occur if:
  • Patient stops taking medication
  • Eats food that is too salty
  • Has a stressful illness
  • New Heart Attack
  • Abnormal Heart Rhythm

• Some patient's do not have heart disease
• Other Causes may Include:
  • Poisonings from Inhaling Toxix Smoke or Chemical Fumes
  • Traumatic Chest Injuries

COPD

Chronic Obstructive Pulmonary Disease

• 10% - 20% US
• End of a slow process
• Disruption of:
  • Airways
  • Alveoli
  • Pulmonary Blood Vessels

• The process may be the result of:
• Direct Airway Damage from repeated infection 
• Inhalation of Toxic Agents (Industrial gases/particles)
• Most often from smoking
• Chronic Bronchitis - on-going irritation of the trachea and Bronchi
  • Excess mucus - obstructing small airways and alveoli
  • Protective cells and lung mechanisms are destroyed - weakening airways
  • Chronic oxygenation can lead to right heart failure & fluid retention (Edema in the leg)

• Pneumonia develops easily when the passages are persistently obstructed
• Repeated episodes of irritation & pneumonia produce scar tissue and some dilation of the obstructed alveoli

• Loss of the Elastic material around the air spaces, as a result of chronic stretching of the alveoli when inflamed airways obstruct easy expulsion of gases
• Smoking can also destroy lung tissue elasticity so large holes are created 

• Lungs sounds:
  • crackling
  • Rales
  • Rhonchi
  • Wheezes

Asthma

• Kills 4 - 5 thousand/yr
• An acute spasm of the bronchioles
• Associated with:
  • Excessive Mucus Production
  • Swelling of the Mucus Lining of the Respiratory Passages
• Produces wheezing upon exhale

• In some cases airways are so blocked - no movement is heard
• In some cases exhalation is tiring and cyanosis and/or respiratory arrest may quickly develop (even within minutes)
• Usually the result of an allergic reaction to an inhaled, ingested, or injected substance

• The substance is not the cause of the allergic reaction
• It is an exaggerated response of the body's immune system to that substance
• In some cases there is no identifiable substance
• Can also be caused by severe emotional distress, exercise, or respiratory infections
• In the most severe form it can produce anaphylaxis and even anaphylactic shock
• May cause severe respiratory distress to result in coma or death

Spontaneous Pneumothorax

• Surface of the lung is disrupted
• Air escapes into the pleural cavity
• Negative vacuum pressure is lost
• Natural elasticity of the lung is lost
• Lungs collapse
• most often caused by trauma, some medical conditions, weak areas of the lung
• emphysema & asthma patients at high risk

• Can becomes dyspneic
• Can complain of pleuritic chest pain - sharp stabbing pain on 1 side, worse during breathing, or certain chest movement
• Sometimes hear that decreased or absent breath sounds on one side
• May be the cause of sudden dyspnea with underlying emphysema

Anaphylaxtic Reactions

• Severe allergic reaction
• Airway swelling and dilation of blood vessels all over the body
• May lower BP significantly
• May be associated with wide spread itching and asthma symptoms
• Airway mat swell from partial obstruction to total obstruction in a few minutes
• Most occur within 30 mins. of exposure

Pleural Effusions

• A collection of fluid outside the lung on 1 or both sides
• Compresses the lung causing dyspnea
• Fluid may collect in large volumes in response to irritation, infection, CHF, or cancer
• Can build up gradually
• patients report that dyspnea came on suddenly

• Contributing diagnosis w/ cancer and shortness of breath
• Hear decreased breath sounds over the region where fluid has move lung away from the chest wall
• Patient's generally feel better if sitting upright
• Only removal of fluid, done in hospital, will relieve symptoms

Mechanical Obstruction of the Airway

• Dyspneic patients may have a mechanical obstruction
• Semi-conscious/conscious patients - may be vomitus or foreign object, head position = tongue
• Head-tilt-chin lift may solve problem (no neck injury)
• Assess upper airway for obstruction
• Foreign body - eating just before, children

Pulmonary Embolism

• Embolus - Anything in the circulatory system that moves from its point of origin  to a distant sight and lodges there obstructing blood flow in that area
• Circulation can be markedly decreased or completely cut off = life threatening
• Can be fragments of blood clots (arterey or vein) that break off and travel through the blood stream
• Can be foreign bodies (in the circulation) such as a bullet or air bubble

• The passage of a blood clot formed in a vein (legs, pelvis - usually) that breaks off and circulates through the veinous system
• Moves through the Right side of the heart and into the pulmonary artery where it becomes lodged
• Sig. blocking blood flow
• No exchange of Oxygen & CO² occurs

• Level arterial of CO2 rises, Oxygen level drops enough to cause cyanosis
• Clots can inhibit circulation
• Cause sig. dyspnea
• May occur as a result of:
  • Damage to the lining of the vessels
  • Tendency of the blood to clot too fast
  • Slow blood flow in a lower extremity (most often)

• Difficult to diagnose
• 650,000 times in US
• 10% are immediately fatal
• Usually patients never notice them
• Complete and sudden obstruction of the output of blood from the Right side of the heart can arise in sudden death

• Dyspnea
• Acute Chest Pain
• Hemoptysis - coughing up blood
• Cyanosis
• Tachypnea
• Varying degrees of hypoxia

Hyperventilation Syndrome

• Over breathing to the point that the level of arterial CO² falls below normal
• May be an indicator of major life-threatening illness
• eg. diabetic w/ very high glucose levels, OD on aspirin, severe infection
• Rapid deep breathing - body's attempt to stay alive
• Body is trying to compensate for acidosus
• Dyspnea w/ no lung abnormailties

• Acidosis is the build up of excess acid in the blood or body tissues that results from the primary illness
• CO² mixed with water in the blood stream can add to the blood acidity
• Lowering the level of CO² helps to compensate for the other acids

• Blood acidity can be diminished by excessive breathing - blows off too much CO² = relative lack of acids - resulting in alkalosis (build up of excess base in body fluids)
• Alkalosis - cause of many symptoms associated w/ hyperventilation Syndrome

• Anxiety
• Dizziness
• Numbness
• Tingling of hands and feet
• Sense of dyspnea, despite the rapid breathing
• Common during psychological stress (10% of population)
• More than 40 shallow breaths/min
• Low as only 20 very deep breaths/min

• Give supplemental Oxygen
• Transport

Assessment of The Patient in Respiratory Distress

• Calm and systematic
• May be the most ill of all patients
• 1st thought = BSI (gloves - min, then mask safety glasses or face shield)
• Safe access and lifting of patient
• May need to consider a toxic substance (inhaled, absorbed, ingested)
• Consider MOI
• Need to determine spinal immobilization
• Determine # of patients
• Need for additional resources

• Gain initial impression, is the patient:
  • Calm
  • Anxious
  • Restless
  • Listless & tired
• To determine whether the patient is stable or unstable

• Stable condition will not deteriorate during treatment & transport
• Unstable condition will deteriorate during treatment and transport (eg. stung by a bee - trouble breathing)
• Determine Level of consciousness using AVPU

• What is patient's Chief Complaint
• If patient is unresponsive:  ABC's

• AB's (no C)
• If no to any, problem:
• Position patient
• Insert Oral airway
• Respiratory Distress - administer Oxygen at 15L/min - nonrebreathing mask
• BVM - breathing rate is too slow or inadequate depth

• If patient is breathing - pulse will be present
• Evaluate adequacy of pulse - indication of breathing status
• Rate = normal , patient has enough Oxygen to support life
• Pulse rate too fast or slow - may not be getting enough oxygen

• Assess circulation includes:
  • Evaluation of Shock and Bleeding
  • Respiratory distress can be a result of:
  • Lack of Red Blood Cells (loss of perfusion)
  • Chronic Anemia
  • Wound
  • Internal Bleeding
  • Shock

• Last step:
• Stable - no life threats:
• May decide to take a focused history and physical exam on scene
• Unstable - possible life-threat:
• Proceed with Rapid Transport
• Provide only life-saving interventions on scene
• Focused history and physical exam enroute

Assessment of The Patient in Respiratory Distress

Focused History and Physical Exam

• SAMPLE
• OPQRST:
  • Onset
  • Provocation
  • Quality
  • Region & Radiation
  • Severity
  • Time
• Ask open-ended questions

• What has patient already done
• When
• How many doses
• Does patient use more than 1 inhaler
• Record name of each inhaler and when last used
• Determine patient's baseline status
• What is different this time - they called 911

COPD:

• Usually older than 50
• History of recurring lung problems
• Almost always smokers
• May complain of chest tightness and constant fatigue
• Chest may have a barrel-like appearance
• Will hear abnormal breath sounds or hard to hear, high in posterior chest:
  • Crackles
  • Ronchi
  • Wheezing

• May often experience:
• Pulmonary Edema - fluid back up into the lungs
• High BP and low cardiac output
• Most sick patients
• Drowning in their own fluid
• May have pink, frothy sputum (mouth)
• Will have adventitious lung sounds 
• Legs and feet may be swollen (pedal edema)

• Pulse
• Respirations
• BP
• Skin - color
• Capillary Refill
• Level of consciousness
• Pain Measurement

• May be used later to determine trends
• Look at the whole clinical picture!
• Patients initially compensate for Respiratory Distress by increasing their Respiratory and Heart Rates
• If able to maintain adequate oxygenation - they will be able to maintain their level of consciousness, skin color, and capillary refill time

• BP will vary with the patient's baseline status
• BP often elevated in Pulmonary Edema (due to CHF)
• Drop Oxygen levels may manifest as:
  • Confusion
  • Lack of coordination
  • Bizarre Behavior
  • Combativeness
• Change in affect or level of consciousness - early sign of Respiratory Inadequacy

• Cyanosis is a late sign - seen 1^st in the lips and mucus membranes
• Ominous sign 
• Requires immediate & Aggressive intervention
• Pulse oximetry helps (wave form, signal quality)
  • If the reading jumps around - disregard
  • Correlate reading w/ patient's clinical condition

• Pulse oximeter can help determine the severity of the respiratory component of the patient's problem
• Ventilatory status prior to manifestation in patient's appearance or vital signs
• Conditions that can skew results:
  • Bright light
  • Dark pigmented skin
  • nail polish
  • patient w/ low hemoglobin (anemic, hypovolemic) may have 100% saturation, but reading doesn't tell you it's not sufficient to sustain organ function
  • Sickle Cell
  • Carbon-monoxide poisoning

• Problems not an immediate threat:
  • Oxygen via a nonrebreathing mask at 15L/min
  • BVM - Positive pressure ventilations
  • Pocket- mask
  • Flow-Restricted Oxygen powered Oxygen device

• After all life-threatening situations taken care of
• CHF:
  • Elevated BP
  • Pedal Edema
• Repeat initial assessment
• Repeat Vital signs
• Focused reassessment of respiratory system
• Ask if treatment made a difference
• Observe chest
• Listen to patient's speech pattern

• Contact Medical Control w/ any change in level of consciousness or difficulty breathing
• Contact medical control prior to assisting w/ any prescribed medications
• Document any changes, and at what time, any orders given by Medical Control

Emergency Care of Patient's in Respiratory Distress

• When taking Vital signs pay particular attention to respirations
• Speak with assurance (calm patient)
• Administer Oxygen (usually)
• Monitor respiration as you admin oxygen
• Reevaluate respirations & patient's response every 5 mins.
• Person with chronically high CO² levels - critical -Oxygen may cause rapid rise in arterial Oxygen level - may abolish hypoxic drive = respiratory arrest

• Assist breathing w/ BVM if patient becomes unconscious
• Supplemental oxygen if patient complains of breathing difficulty
• Nonrebreathing mask @ 10L - 15L/min which enough to maintain the reservoir bag
• Low flow oxygen for long-standing COPD
• 2L/min to 3L/min etc until symptoms have improved

Prescribed Inhalers

• Call Medical Control
• Report what the medication is
• When patient last took a puff and how many
• What label states - dosage
• Assist patient's in using inhaler
• Make sure inhaler belongs to the patient and has not expired, and the correct dosage is being administered

• Most relax the muscles that surround the bronchioles
• Dilation of airways
• Common side effects foe rescue:
  • increased pulse rate
  • nervousness
  • muscle tremors

• Proventil, Ventolin, Volmax = Albuterol
  • Asthma, Bronchitis, COPD
• Atrovent = ipratropium bromide
  • Asthma, Bronchitis, COPD
• Alupent = metaproterenol sulfate
  • Asthma, Bronchitis, COPD

• Beclovent = beclomethasone dipropionate
• Intal = cromolyn sodium
• Flovent = fluticasone propionate
• Advair Diskus = fluticasone propinate, salmeterol xinafoate
• Singulair = montelukast sodium

• Servent = salmeterol xianafote
  • Asthma, Bronchitis,  COPD

Pediatric Needs for Asthma

• Look for retraction above the sternum and between ribs
• Cyanosis is a late finding
• Cough may present vs acute wheeze
• Provide oxygen via blow-by (perhaps parent holds) for children who cannot tolerate the mask
• Use MDI, as with adults

For patients with Upper Airway Infections

Provide

• Humidified Oxygen ( if possible)
• These may cause spasm and complete airway obstruction:
  • Do not suction the airway
  • Do not place an oropharyngeal airway - if epiglottitis is suspected
• Transport promptly
• Allow patient to sit in a comfortable position

• Comfortable Position for epiglottitis is usually sitting upright, leaning forward (sniffing position)
• Dyspnea of Pneumonia is caused by loss of effective lung volume and need for more rapid air exchange - no use of artificial airways - deliver oxygen

• Dyspnea of Acute Pulmonary Edema may be associated with cardiac disease or direct lung damage
• Administer 100% Oxygen
• Carefully suction secretions from the airway
• Prompt transport
• Usually sitting up position
• Positive pressure ventilation and suctioning for unconscious patients

• Assist with prescribed inhaler
• Often times, patient over uses, so watch for side-effects
• Transport ASAP
• Allow patients to sit upright

• Supplemental Oxygen
• Rapid Transport
• Sitting up - more comfortable
• Monitor carefully - sudden deterioration
• Be prepared to support the airway
• Assist respirations
• Give full cardio-pulmonary support

• Ask about how and when symptoms began
• Pulse Rate will be normal or elevated
• BP may be slightly elevated
• Respirations will be increased
• Assist with prescribed MDI
• Administer Oxygen, be prepared to suction (no more than 15 secs. - adults 10 secs - children;  5 sec. infants)

• Allow patient to sit in an upright position
• Provide airway management for unconscious patients
• Reassess breathing frequently
• Be prepared to assist ventilations - last resort
• Provide Slow gentle breathes  10 - 12 shallow breathes/min(as problem is exhalation)

• True Emergency
• Must be given oxygen
• Transport immediately
• ALS should be considered

• Removal of fluid out side the lung - hospital
• Provide oxygen and other routine support measures

• If eating just before - check for food obstruction
• May be Partial or Complete
• Partial - provide oxygen - transport sitting up
• Complete - BLS to clear the airway - transport ASAP

For patients with Obstruction of the Upper Airway

Pulmonary Embolism

• Lung tissue may not be functioning - may cause Cardiac Arrest:
• Supplemental Oxygen is Mandatory
• Place patient in comfortable position (sitting)
• Assist breathing as needed
• clear coughed-up blood from hemoptysis
• May have unusually rapid or irregular
• Transport ASAP

• Complete initial assessment & History of event
• Is patient having chest pain?
• History of cardiac problems or diabetes?
• Always assume a serious underlying problem (even stress) 
• Reaasuring patient
• Supply suplemental oxygen
• Prompt Transport