chest compressions (CPR).
Since the pulse in adults will usually increase when there is a lack of oxygen, a pulse that remains the same or increases may indicate inadequate artificial ventilation. Naturally, if the pulse disappears this indicates that the patient is in cardiac arrest and need
How to identify and treat a patient with breathing difficulty
This includes the following:
■ Altered mental status, including restlessness, anxiety, or depressed level of consciousness
■ Unusual anatomy (barrel chest)
■ The patient's position:
• Tripod position (patient leaning forward with hands on knees or another surface)
• Sitting with feet dangling, leaning forward
■ Work of breathing, including
• Use of accessory muscles to breathe
• Flared nostrils
• Pursed lips
• The number of words the patient can say without stopping, described as one-word
dyspnea, two-word dyspnea, for example
■ Pale, cyanotic, or flushed skin
■ Pedal edema, swelling around the calves, ankles, and feet
■ Sacral edema, swelling around the low back in bedridden patients
■ Noisy breathing, which may be described as:
• Audible wheezing (heard without stethoscope)
• Stridor (harsh, high-pitched sound during breathing, usually due to upper airway
■ Lung sounds on both sides during inspiration and expiration
Evaluating Vital Sign Changes, Which May Include:
■ Increased pulse rate
■ Decreased pulse rate (especially in infants and children)
■ Changes in the breathing rate (above or below normal levels)
■ Changes in breathing rhythm
■ Hypertension or hypotension
■ Oxygen saturation, or SpO2, reading of less than 95 percent on the pulse oximeter
Chronic Obstructive Pulmonary Disease (COPD)
Emphysema—as well as chronic bronchitis, black lung, and many undetermined respiratory illnesses that cause the patient problems like those seen in emphysema—are all classified as
chronic obstructive pulmonary disease (COPD).
COPD is mainly a problem of middle-aged or older patients. This is because these disorders take time to develop as tissues in the respiratory tract react to irritants. Cigarette smoking causes the overwhelming majority of cases of COPD. Occasionally other
irritants such as chemicals, air pollutants, or repeated infections cause this condition.
Describe the anatomy and physiology of
respiration. (pp. 444-445)
make sure you are familiar with the following
structures of the respiratory system: nose, mouth, oropharynx, nasopharynx, epiglottis, trachea, cricoid cartilage, larynx, bronchi, lungs, alveoli, and diaphragm.
an ACTIVE PROCESS in which the
intercostal (rib) muscles and the
diaphragm CONTRACT, expanding the
size of the chest cavity and causing
air to flow into the lungs.
a passive process in which the
intercostal (rib) muscles and the
diaphragm relax, causing the chest
cavity to decrease in size and forcing
air from the lungs.
are high-pitched sounds that will seem almost musical in nature. The sound is created by air moving through narrowed air passages in the lungs. It can be heard in a variety of diseases but is common in asthma and sometimes in chronic obstructive lung diseases such as emphysema and chronic bronchitis. This abnormal breathing sound is the most commonly heard during expiration.
are (as the name indicates) a fine crackling or bubbling sound heard upon inspiration. The sound is caused by fluid in the alveoli or by the opening of closed alveoli. Some people refer to crackles as rales.
are lower-pitched sounds that resemble snoring or rattling. They are caused by secretions in larger airways as might be seen with pneumonia or bronchitis or when materials are aspirated (breathed) into the lungs. The difference between crackles and rhonchi is not always obvious and is somewhat subjective. However, rhonchi
generally are louder than crackles.
is a high-pitched sound that is heard on inspiration. It is an upper-airway sound indicating partial obstruction of the trachea or larynx. Stridor is usually audible without a stethoscope.
Rates of breathing that are considered normal vary by age. For an adult, a normal rate is 12-20 breaths per minute. For a child, it is 15-30 breaths per minute. For an infant, it is 25-50 breaths per minute.
Rhythm. Normal breathing rhythm will usually be regular. Breaths will be taken at regular intervals and will last for about the same length of time. Remember that talking and
other factors can make normal breathing slightly irregular.
Breath sounds, when auscultated with a stethoscope, will normally be present and equal when the lungs are compared to each other. When observing the chest cavity, both sides should move equally and adequately to indicate a proper air exchange. The depth of the respirations must be adequate.
Respiratory problems and conditions
are the leading killer of Infants and Children. With this in mind, you must begin respiratory treatment of infants and
children with a thorough and accurate assessment and prompt, proper care.
Adult Breathing Rate: 12-20/Minute;
Child Breathing Rate: 15-30/Minute;
Infant Breathing Rate: 25-50/minute
Regular Breathing Rhythm
Quality Breath Sounds that are Present and Equal
Chest Expansion that are Adequate and Equal
Effort of Breathing that are Unlabored with normal respiratory effort
breathing that is not sufficient to support life.
Breathing Rate is Above or below normal rates for the patient's age
Breathing Rhythm May be irregular
Quality Breath Sounds are Diminished, unequal, or absent
Chest Expansion are Inadequate or unequal
Effort of Breathing is Labored: increased respiratory effort; use of
accessory muscles (may be pronounced in infants
and children and involve nasal flaring, seesaw
breathing, grunting, and retractions between the
ribs and above the clavicles and sternum)
Depth of Breathing is Too shallow
Be aware that some signs of inadequate breathing in
infants and children
Nasal flaring (widening of the nostrils)
Retractions (pulling in of the muscles) between the ribs (intercostal), above the clavicles
(supraclavicular), and above the sternum (suprasternal)
In order of preference, the means of providing assisted
1. Pocket face mask with supplemental oxygen
2. Two-rescuer bag-valve mask with supplemental oxygen
3. Flow-restricted, oxygen-powered ventilation device
4. One-rescuer bag-valve mask with supplemental oxygen
Oxygen by nonrebreather mask or nasal cannula.
• Rate and depth of
• No abnormal breath
• Air moves freely in
and out of the chest.
• Skin color normal.
Assisted ventilations (air put into the lungs under pressure) with a pocket face mask, bag-valve mask, or FROPVD. adjusting rates for rapid or slow breathing. Note: A nonrebreather mask requires adequate breathing to pull oxygen into the lungs. It DOES NOT provide ventilation if patient is not breathing or is breathing inadequately.
• Patient has some breathing but not enough to live.
• Rate and/or depth outside of normal limits.
• Shallow ventilations.
• Diminished or absent breath sounds.
• Noises (crowing, stridor, snoring, gurgling, or gasping).
• Blue (cyanosis) or gray skin color.
• Decreased minute volume.
Immediately verify a pulse. If pulse present, provide ventilations with a pocket face mask, bag-valve mask, or FROPVD at 12/minute for an adult and 20/minute for an
infant or child.
If pulse absent, immediately begin chest compressions
followed by ventilations and apply an AED.
Note: DO NOT use oxygen-powered ventilation devices on
infants or children.
• No chest rise.
• No evidence of air being moved from the mouth or nose.
• No breath sounds.
adequate rate for artificial ventilation
is 12 breaths per minute for adults and 20 per minute for infants and children.
Noisy breathing Obstructed Breathing
which may be described as:
• Audible wheezing (heard without stethoscope)
• Stridor (harsh, high-pitched sound during breathing, usually due to upper airway obstruction)
When a patient is suffering from breathing difficulty, provide the following care:
■ Assessment. Assess the airway during the primary assessment and then frequently
throughout the call. Assist respiration with artificial ventilations and supplemental
oxygen whenever the patient has or develops inadequate breathing.
■ Oxygen. Oxygen is the main treatment for any patient in respiratory difficulty. If the
patient is breathing adequately, use a nonrebreather mask at 15 liters per minute to
provide oxygen. Use a nasal cannula only in cases where the patient will not tolerate
a mask. If the patient has inadequate breathing, provide supplemental oxygen while
performing artificial ventilation.
■ Positioning. If the patient is experiencing breathing difficulty but is breathing ade-
quately, place him in a position of comfort. Most patients with breathing difficulty feel
they can breathe better sitting up. However, this is not possible if the patient has in-
adequate breathing, since the patient would need to be supine to receive assisted
■ Prescribed inhaler. If the patient has a prescribed inhaler, you may be able to as-
sist the patient in taking this medication. This would be done after consultation with
medical direction, often during transportation to the hospital. (More information will
be provided on prescribed inhalers later in this chapter.)
■ Continuous positive airway pressure (CPAP). See the discussion of CPAP that
continuous positive airway pressure (CPAP)
a form of noninvasive positive pressure ventilation (NPPV) consisting of a mask and a means of blowing oxygen or air into the mask to prevent airway collapse or to help alleviate difficulty breathing.
is administered to all patients with respiratory distress regardless of their oxygen saturation readings. Even a patient with a saturation reading of 100 percent should receive oxygen if he has any signs of respiratory distress.
Steps to CPAP
Step 1 Assess the patient and ensure that he meets the
criteria for CPAP.
Step 2 Explain the device to the patient. The mask and snug
seal may initially cause the patient to feel smothered
Step 3 Apply the mask to the patient's face. Continue to calm
and reassure the patient.
Step 4 Use settings as defined in your protocols.
Step 5 Reassess and monitor the patient.
Step 6 Discontinue CPAP and ventilate the patient if
breathing becomes inadequate.
Patient's subjective perception
Feeling of labored, or difficult, breathing
Amount of distress felt may or may not reflect actual severity of condition
Stridor—high-pitched, upper-airway sounds indicating partial obstruction of trachea or larynx
Assure adequate ventilations
If breathing is inadequate, begin artificial ventilation
If breathing is adequate, non-rebreather mask at 15 Lpm
: Use a nasal cannula only in cases where the patient will not tolerate a mask. If the patient has inadequate breathing, provide supplemental oxygen while performing artificial ventilation.
Chronic Obstructive Pulmonary Disease
Broad classification of chronic lung diseases
Includes emphysema, chronic bronchitis, and black lung
Overwhelming majority of cases are caused by cigarette smoking
COPD: Chronic Bronchitis
Bronchiole lining inflamed
Excess mucus produced
Cells in bronchioles that normally clear away mucus accumulations are unable to do so
Alveoli walls break down—surface area for respiratory exchange is greatly reduced
Lungs lose elasticity
Results in air being trapped in lungs, reducing effectiveness of normal breathing
Many COPD patients exhibit characteristics of both emphysema and chronic bronchitis.
Chronic disease with episodic exacerbations. During attack, small bronchioles narrow (bronchoconstriction); mucus is overproduced
Results in small airway passages practically closing down, severely restricting air flow. There is no known way to prevent asthma, but episodes of distress can often be prevented by use of appropriate medications and careful attention to avoiding items that trigger attacks. Air flow mainly restricted in one direction
Inhalation—expanding lungs exert outward pull, increasing diameter of airway and allowing air flow into lungs
Exhalation—opposite occurs and air becomes trapped in lungs
Asthma is a chronic disease that has episodic exacerbations. Narrowing of small bronchial tubes and overproduction of mucus impedes airflow and causes gas exchange problems.
Abnormal accumulation of fluid in alveoli
Congestive heart failure (CHF) patients may experience difficulty breathing because of this
Pulmonary edema typically occurs due to a dysfunction of the left ventricle. Fluid accumulates in and around the alveoli and disrupts gas exchange.
Pressure builds up in pulmonary capillaries
Fluid crosses the thin barrier and accumulates in and around alveoli
Fluid occupying lower airways makes it difficult for oxygen to reach blood
Patient experiences dyspnea
Common signs and symptoms of Pulmonary Edema
Pale and sweaty skin
In severe cases, crackles or sometimes wheezes may be audible
Patients may cough up frothy sputum, usually white, but sometimes pink-tinged
Treatment Pulmonary Edema
Assess for and treat inadequate breathing
If possible, keep patient's legs in dependent position
Infection of one or both lungs caused by bacteria, viruses, or fungi
Results from inhalation of certain microbes
Microbes grow in lungs and cause inflammation
occurs due to an infection in the lungs and can interfere with normal gas exchange.
Signs and symptoms of Pneumonia
Shortness of breath with or without exertion
Fever and severe chills
Chest pain (often sharp and pleuritic)
Pale, sweaty skin
Treatment of Pneumonia
Care mostly supportive
Assess for and treat inadequate breathing
Lung collapses without injury or other obvious cause
Tall, thin people, and smokers are at higher risk for this condition
occurs when air builds up in the space between the lung and the chest wall. The pressure can collapse the lung.
is usually the result of rupture of a bleb, a small section of the lung that is weak. Once the bleb ruptures, the lung collapses and air leaks into the thorax.
Signs and symptoms of Spontaneous Pneumothorax
Sharp, pleuritic chest pain
Decreased or absent lung sounds on side with injured lung
Shortness of breath/dyspnea on exertion
Low oxygen saturation, cyanosis
Treatment of Spontaneous Pneumothrax
Transport for definitive care, as patients frequently require chest tube
patients can rapidly decompensate. Reassess frequently.
Blockage in blood supply to lungs
Commonly caused by deep vein thrombosis (DVT)
Increased risk from limb immobility, local trauma, abnormally fast blood clotting
Pulmonary emboli are arterial obstructions in the pulmonary blood flow. These blockages can disrupt perfusion of lung tissue.
Patients at increased risk for developing a DVT include women on birth control pills, patients with cancer, patients with lower extremity injuries (such as casted fractures), and anyone who is in the same position for a long period of time (such as transcontinental air travelers).
Signs and symptoms of Pulmonary Embolism
Shortness of breath
Low oxygen saturation/cyanosis
Treatment of Pulmonary Embolism
Difficult to differentiate in field
Transport to definitive care
Infection causing swelling around glottic opening
In severe cases, swelling can cause airway obstruction
used to be a disease of children, but it is now much less common in children than in adults in the United States. This is primarily the result of childhood vaccination against Haemophilus influenzae type B, the bacterium that used to cause most cases of epiglottitis in children.
Signs and symptoms of Epiglottitis
Sore throat, drooling, difficult swallowing
Preferred upright or tripod position
Treatment of Epiglottitis
Keep patient calm and comfortable
Do not inspect throat
Administer high-concentration oxygen if possible without alarming patient
Genetic disease typically appearing in childhood
Causes thick, sticky mucus accumulating in the lungs and digestive system
Mucus can cause life-threatening lung infections and serious digestion problems
Signs and symptoms of Cystic Fibrosis
Coughing with large amounts of mucus
Frequent occurrences of pneumonia
Abdominal pain and distention
Coughing up blood
Treatment of Cystic Fibrosis
Caregiver often best resource for baseline assessment of patient
Caregivers can often guide treatment
Assess for, and treat, inadequate breathing
Viral Respiratory Infections
Infection of respiratory tract
Usually minor but can be serious, especially in patients with underlying respiratory diseases like COPD
Often starts with sore or scratchy throat with sneezing, runny nose, and fatigue
Fever and chills
Infection can spread into lungs, causing shortness of breath
Cough can be persistent; may produce yellow or greenish sputum
The Prescribed Inhaler
Provides a metered (exactly measured) inhaled dose of medication
Most commonly prescribed for conditions causing bronchoconstriction
The metered-dose inhaler gets its name from the fact that each activation provides a measured dose of medication. A metered-dose inhaler is typically prescribed for patients with respiratory problems that cause bronchoconstriction.
Before administering inhaler
Right patient, right medication, right dose, right route
Check expiration date
Shake inhaler vigorously
Patient alert enough to use inhaler
Use spacer device if patient has one
As an EMT you may be allowed to assist a patient in using a prescribed inhaler. You will need to get permission from medical direction to help the patient use the inhaler. This may be accomplished by phone/radio or by standing order, depending on your local protocols.
To administer inhaler
Have patient exhale deeply
Have patient put lips around opening
Press inhaler to activate spray as patient inhales deeply
Make sure patient holds breath as long as possible so medication can be absorbed
The Small-Volume Nebulizer
Medications in metered-dose inhalers can also be administered by a small-volume nebulizer (SVN)
Nebulizing—running oxygen or air through liquid medication
Patient breathes vapors created
Produces continuous flow of aerosolized medication that can be taken in during multiple breaths over several minutes
Gives patient greater exposure to medication
Many medications administered in a metered-dose inhaler also can be administered through a small-volume nebulizer. Nebulization involves running oxygen or air through a liquid medication to create vapors that the patient can inhale.
Prescribed Inhaler—Patient Assessment and Management
Step 1 The patient has the indications for use of an inhaler:
signs and symptoms of breathing difficulty and an
inhaler prescribed by a physician.
Step 2 Contact medical direction and obtain an order to assist
the patient with the prescribed inhaler.
Step 3 Ensure the five "rights":
• Right patient
• Right time
• Right medication
• Right dose
• Right route
Step 4 Coach the patient in the use of an inhaler. Tell him he
should exhale deeply, press the inhaler to activate the
spray, inhale, and hold his breath in so medication can
Check the expiration date, shake the inhaler, make
sure the inhaler is room temperature or warmer, and
make sure the patient is alert.
Step 5 After use of the inhaler, reassess the patient: take vital
signs, perform a focused exam, and determine if
breathing is adequate.
1. Generic: albuterol, isoetharine, metaproterenol
2. Trade: Proventil, Ventolin, Bronkosol, Bronkometer,
Meets all the following criteria:
1. Patient exhibits signs and symptoms of respiratory
2. Patient has physician-prescribed handheld inhaler.
3. Medical direction gives specific authorization to use.
1. Patient is unable to use the device (e.g., not alert).
2. Inhaler is not prescribed for the patient.
3. No permission has been given by medical direction.
4. The patient has already taken the maximum
prescribed dose prior to the EMT's arrival.
Handheld metered-dose inhaler.
Number of inhalations based on medical direction's order or
1. Obtain an order from medical direction, either on-line
2. Ensure the right patient, right time, right medication,
right dose, right route, and patient is alert enough to
use the inhaler.
3. Check the expiration date of the inhaler.
4. Check if the patient has already taken any doses. 5. Ensure the inhaler is at room temperature or warmer.
6. Shake the inhaler vigorously several times.
7. Have the patient exhale deeply.
8. Have the patient put her lips around the opening of
9. Have the patient depress the handheld inhaler as she
begins to inhale deeply.
10. Instruct the patient to hold her breath for as long as
she comfortably can so the medication can be
11. Put the oxygen back on the patient.
12. Allow the patient to breathe a few times and repeat
the second dose if so ordered by medical direction.
13. If the patient has a spacer device for use with her
inhaler (device for attachment between inhaler and
patient to allow for more effective use of medication),
it should be used.
Beta-agonist bronchodilator dilates bronchioles, reducing
1. Increased pulse rate
1. Gather vital signs.
2. Perform a focused reassessment of the chest and
3. Observe for deterioration of the patient; if breathing
becomes inadequate, provide artificial respirations.
Small-Volume Nebulizer (SVN)—Patient Assessment and Management
Step 1 Identify the patient as a candidate for nebulized
medication per protocol (e.g., history of asthma with
respiratory distress). Administer oxygen and assess vital
signs. Be sure the patient is not allergic to the medication.
Step 2 Obtain permission from medical direction to administer
or assist with the medication.
Step 3 Ensure the five rights (right patient, right time, right
medication, right dose, right route). Prepare the nebulizer.
Put the liquid medication in the chamber. Attach the
oxygen tubing and set the oxygen flow for 6 to 8 liters per
minute (or according to manufacturer's recommendations).
Step 4 Have the patient seal his lips around the mouthpiece
and breathe deeply. Instruct the patient to hold his
breath for 2 to 3 seconds if possible. Continue until the
medication is gone from the chamber.
constriction, or blockage, of the bronchi
that lead from the trachea to the lungs.
Differences between adult and child/infant respiratory systems include:
• Mouth and nose—In general, all structures are smaller and more easily obstructed in
children than in adults.
• Pharynx—Infants' and children's tongues take up proportionally more space in the
mouth than do adults'.
• Trachea—The trachea is narrower and obstructed more easily by swelling; it is also
softer and more flexible. Like other cartilage in the infant and child, the cricoid car-
tilage is less developed and less rigid.
• Diaphragm—The chest wall is softer; infants and children tend to depend more
heavily on the diaphragm for breathing.
Signs and symptoms of breathing difficulty
include altered level of consciousness, dizziness, fainting, restlessness, anxiety, confusion, combativeness, cyanosis, straining neck and facial muscles, tightness in the chest, straining intercostal muscles, numbness or tingling in the hands and feet, flaring nostrils, pursed lips, coughing, crowing, high-pitched
barking, respiratory noises such as wheezing or rattling, and the patient sitting in a tripod position.
simply measures the amount of oxygen being carried on red blood cells in the bloodstream; this is just one measure of what's going on in the body. The patient may be in moderate to severe distress and yet be showing a "normal" pulse oximetry reading. In fact, the patient's tissues might be quite hypoxic if oxygen molecules are not being released from red blood cells when they reach, for example, the brain.There are even some conditions, like a low body temperature of low acid level in the body, that cause oxygen
to stay attached to red blood cells instead of oxygenating tissues, leading to hypoxia.This is why you must assess the whole patient—all vital signs including the SpO2 reading.