Chapter 21
Respiratory
Disorders
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21-1
Objectives
21-2
Assessing the Patient with
Breathing Difficulty
21-3
Scene Size-Up
• Determine mechanism of injury or
nature of the illness.
– Spinal stabilization if trauma is suspected
• Observe the patient’s environment.
21-4
General Impression
• Appearance
– Mental status
– Body position
• Work of breathing
• Skin color
21-5
Primary Survey
• Mental status
• Airway
• Breathing
– Bradypnea
– Tachypnea
– Agonal breathing
21-6
Breathing
• Decreased respiratory rate—possible
causes
– Drug overdose
– Respiratory distress
– Respiratory failure
– Head injury
– Hypothermia
21-7
Breathing
• Increased respiratory rate – possible
causes
– Fever
– Pain
– Anxiety
– Respiratory distress
– Respiratory failure
– Certain drugs
– Increased metabolic rate
– Hypoxia
– Trauma
– Diabetic ketoacidosis
21-8
Breathing
• Breathing depth / equality
– Tidal volume
– Minute volume
21-9
Breath Sounds
• Compare from side to side (bilaterally)
• Determine if breath sounds are
– Present or absent
– Equal or unequal
– Clear or noisy
21-10
Abnormal Breath Sounds
Breath Sound
Description
Crackles (rales)  Short popping or
crackling sounds
 Heard more often on
inhalation than on
exhalation
What It Means
Movement of air
through moisture or
fluid
Rhonchi
 “Rattling” or “rumbling”
sounds
Wheezes
 High- or low-pitched
Movement of air
whistling sounds
through narrowed lower
 Usually heard at the end airways
of inhalation or on
exhalation
Movement of air
through mucus or fluid
21-11
Breathing
• Rhythm
• Work of breathing
– Retractions
• Supraclavicular
• Intercostal
• Subcostal
21-12
Noisy Breathing
• Normal breathing is quiet.
• Noisy breathing is usually a sign that
the patient is in distress.
– Stridor
– Snoring
– Wheezing
– Gurgling
– Grunting
21-13
Circulation and Perfusion
• Estimate the heart rate.
• Note regularity and strength of the
pulse.
• Note skin color, temperature, and
moisture.
• Assess capillary refill in children
younger than 6 years of age.
• If appropriate, assess for possible major
bleeding.
21-14
Priority Patients
• Priority patients include the following:
– Those in whom an open airway cannot be
established or maintained
– Those who are experiencing difficulty
breathing or who exhibit signs of
respiratory distress
– Those with absent or inadequate breathing
and who require continuous positivepressure ventilation
21-15
Signs and Symptoms of
Breathing Difficulty
• Shortness of breath
• Restlessness
• Possible altered mental
status
• Breathing rate too fast
or slow for age
• Irregular breathing
pattern
• Depth of breathing
unusually deep or
shallow
• Noisy breathing
• Sitting upright, leaning
forward to breathe
• Unable to speak in
complete sentences
• Pain with breathing
• Retractions, use of
accessory muscles
• Abdominal breathing
• Coughing
• Increased pulse rate
• Unusual anatomy
(barrel chest)
• Flushed, pale, gray, or
blue skin
21-16
Secondary Survey
SAMPLE History
• Can you tell me why you called us
today?
• Allergies
• Medications
– Prescribed inhaler?
•
•
•
•
Past medical history
Last oral intake
Events prior
Additional pertinent questions
21-17
Secondary Survey
OPQRST
• Onset
• Provocation / Palliation / Position
• Quality
• Region / Radiation
• Severity
• Time
21-18
Secondary Survey
Physical Exam
• If responsive
– Focused exam
• If unresponsive or altered mental status
– Rapid medical assessment
21-19
Infant and Child
Assessment Considerations
21-20
Infants and Children
• Nasal passages
– Nasal flaring
– Head bobbing
21-21
Infants and Children
• Tongue
• Glottic opening
• Epiglottis
21-22
Infants and Children
• Trachea
• Ribs
– Seesaw breathing
21-23
Infants and Children
• Respiratory rate
• Skin color changes
21-24
Determining the Patient’s
Level of Respiratory Distress
21-25
Levels of Respiratory Distress
1. No breathing difficulty or shortness of
breath
2. Mild breathing difficulty
3. Moderate breathing difficulty
4. Severe breathing difficulty
21-26
No Breathing Difficulty
•
•
•
•
•
•
•
•
•
No signs of respiratory distress
Patient appears relaxed.
Breathing is quiet and unlabored.
Patient able to speak in full sentences
Breathing rate within normal limits for age
Breathing pattern smooth and regular
Equal chest rise and fall
Adequate tidal volume
Normal skin color
21-27
Mild Breathing Difficulty
• Patient may be hypoxic but can move
adequate air.
• Heart rate and respiratory rate may be
increased.
• Patient can answer questions in
complete sentences.
• Give oxygen by nonrebreather mask.
• If indicated, treat with the patient’s MDI.
21-28
Moderate Breathing Difficulty
• Patient may be hypoxic but can still
move adequate air
– Tidal volume may be decreased.
• Patient may be restless and irritable.
• Patient has increased heart rate and
respiratory rate.
• Patient unable to speak in complete
sentences
• Give oxygen by nonrebreather mask.
• Have patient try to use prescribed
inhaler, if possible.
21-29
Assisting Ventilations
• Explain what you are going to do.
• Match squeezing the bag with the
patient’s breathing.
– Do not try to take over
• As patient starts to breathe in, gently
squeeze bag.
– Stop squeezing as chest starts to rise.
– Interpose extra ventilations, if necessary.
– Allow the patient to exhale before giving
the next breath.
• Feel for changes in the patient’s lung
compliance.
21-30
Signs of Adequate Artificial Ventilation
• Chest rise and fall is seen with each
artificial ventilation.
• Rate of ventilation is sufficient.
• Heart rate improves with artificial
ventilation.
21-31
Signs of Inadequate Artificial Ventilation
• Chest does not rise and fall with
artificial ventilation.
• Rate of ventilation is too slow or too
fast.
• Heart rate does not return to normal
with artificial ventilation.
21-32
Severe Breathing Difficulty
• Patient may be sleepy or unresponsive.
• If responsive, patient may be unable to
speak or may only be able to speak
using 1 or 2 words.
• Patient may assume a tripod position.
• Breathing rate may initially be rapid
with periods of slow breathing.
• Skin may appear blue or mottled
despite his being given oxygen.
21-33
Key Points
• Remember:
– An unresponsive patient is unable to
protect her own airway.
– Do not try to insert an oral airway in a
semi-responsive patient.
• Can cause gagging and vomiting
– If necessary, assist an unresponsive
patient’s breathing.
21-34
Specific Respiratory Disorders
21-35
Dyspnea
• Sensation of shortness of breath or
difficulty breathing
• Common chief complaint
– “Short of breath”
– “Short-winded”
– “Can’t catch my breath”
21-36
Dyspnea
Possible Causes
Possible Traumatic Conditions
• Flail chest
• Simple pneumothorax
• Inhalation injury
• Open pneumothorax
• Drowning incident
• Tension pneumothorax
• Pulmonary contusion
• Traumatic asphyxia
• Diaphragm injury
• Scapula fracture
• Tracheobronchial tree
• Rib fractures
injury
21-37
Dyspnea
Possible Causes
Possible Medical Conditions
• Croup
•
•
• Epiglottitis
• Pertussis
•
• Cystic fibrosis
•
• Reactive airway disease •
•
• Allergic reaction
•
• Heart attack
•
• Airway obstruction
• Chronic bronchitis
Emphysema
Acute pulmonary
embolism
Abnormal heart rhythm
Lung cancer
Congestive heart failure
Pneumonia
Foreign body airway
obstruction
COPD
21-38
Croup
• Viral infection
21-39
Croup
• Assessment finding and symptoms
– Gradual onset, usually over two to three
days
– Stridor
– Barking cough
– Hoarse voice
– Low-grade fever (usually less than
102.2°F)
21-40
Croup
• Emergency care
– Position of comfort
– Avoid agitating the child.
– If possible, allow the caregiver to hold the
child
– Give blow-by oxygen if mask not tolerated
– Assist breathing as needed
21-41
Epiglottitis
• Bacterial infection
21-42
Epiglottitis
• Assessment findings and symptoms
– Restlessness
– Tripod position, unwilling to lie down
– Sudden onset of high fever, usually 102° to
104°F
– Sore throat
– Muffled voice
– Drooling, difficulty swallowing
– Dyspnea
– Stridor
21-43
Epiglottitis
• Emergency care
– Observe closely at all times.
– Avoid upsetting the child.
– Position of comfort
– Allow the caregiver to hold the child.
– Blow-by oxygen if mask not tolerated.
– Assist breathing as needed
– Do not attempt to look into the child’s
mouth or throat.
– Rapid transport.
21-44
Comparison of Croup and Epiglottitis
Croup
Age
Cause
Onset
Signs/
symptoms
6 months to 3 years
Viral
Gradual
 Stridor
 Barking cough
 Hoarse voice
 Low-grade fever
(usually less than
102.2°F)
Epiglottitis
3 to 7 years
Bacterial
Sudden
 Stridor
 Restlessness
 Sore throat, drooling
 Muffled voice
 High fever (usually
102°F to 104°F)
 Tripod position,
unwilling to lie down
 Difficulty swallowing
 Dyspnea
 Rapid onset
21-45
Pertussis (Whooping Cough)
• Highly contagious
bacterial infection of the
respiratory tract
• Spread from person to
person by droplets from
coughing and sneezing
• Can affect persons of
any age
21-46
Pertussis
• Assessment findings and symptoms
– Runny nose
– Sneezing
– Low-grade fever
– Severe coughing spasms
– Gagging
– High pitched whooping sound or crowing
– Clear mucus
– Vomiting
21-47
Pertussis
• Emergency care
– Supportive care
– Position of comfort
– Give blow-by oxygen if mask not tolerated
– Assist breathing as needed
– Transport
21-48
Cystic Fibrosis
• Inherited disease
– Defective gene results in an abnormality in
the glands that produce or secrete sweat
and mucus
• Bronchi
– Produce excessive amounts of thick,
sticky mucus
• Pancreas
– Fails to produce the enzymes required for
the breakdown of fats
21-49
Cystic Fibrosis
• Assessment findings
and symptoms:
– Nasal congestion
– Very salty-tasting skin
– Frequent respiratory
infections
– Persistent cough
– Use of accessory
muscles
– Wheezing
– Shortness of breath
– Increased respiratory
rate
– Cyanosis
– Poor growth / weight gain
in spite of a good
appetite
– Abdominal distention
– Abdominal pain /
discomfort
– Thin extremities
– Clubbing
– Greasy, bulky stools
21-50
Cystic Fibrosis
• Emergency care
– Primarily supportive
– Allow the patient to assume a position of
comfort
– Suction as needed
– Give supplemental oxygen
– Monitor vital signs and oxygen saturation
– Transport for additional care
21-51
Asthma
• Widespread,
temporary narrowing
of the air passages
that transport air from
the nose and mouth to
the lungs
• Allergic asthma
• Nonallergic asthma
21-52
Asthma
Possible Triggers
21-53
Asthma
• Assessment findings and symptoms
– Wheezing (most common symptom)
– Restlessness
– Dry cough
– Dyspnea
– Chest tightness
– Rapid breathing
– Increased heart rate
– Retractions
– Use of accessory muscles
21-54
Asthma
• Emergency care
– Position of comfort
– Oxygen
– Assist with prescribed inhaler
– Transport
21-55
Chronic Bronchitis
• Sputum production
for 3 months of a
year for at least 2
consecutive years
• Causes
21-56
Chronic Bronchitis
• Assessment findings and symptoms
– Productive cough
– Cyanosis
– Labored breathing
– Use of accessory muscles
– Increased respiratory rate
– Peripheral edema
– Inability to speak in complete sentences
without pausing for a breath
21-57
Chronic Bronchitis
• Emergency care
– Position of comfort
– Give oxygen
– Assist ventilations as necessary
– Provide calm reassurance
– Assist patient with prescribed inhaler if
necessary
– Transport
21-58
Emphysema
• Irreversible
enlargement of the air
spaces distal to the
terminal bronchioles
21-59
Emphysema
• Assessment findings and symptoms
– Barrel-chest appearance
– Increased work of breathing
– Use of accessory muscles
– Pursed-lip breathing
– Chronic cough
– Prolonged exhalation
– Increased respiratory rate
– Dyspnea with exertion
21-60
Emphysema
• Emergency care
– Position of comfort
– Give oxygen
– Assist ventilations as necessary
– Provide calm reassurance
– Assist patient with prescribed inhaler if
necessary
– Transport
21-61
Pneumonia
• Infection that often affects gas exchange in
the lung
21-62
Pneumonia
• Assessment findings and symptoms
– Fever
– Chills
– Increased respiratory rate
– Increased heart rate
– Possible cough
– Shortness of breath
– Malaise
– Possible pleuritic chest pain
21-63
Pneumonia
• Emergency care
– Position of comfort
– Give oxygen
– Transport
21-64
Pulmonary Embolism
• Risk factors
– Obesity
– Prolonged bed rest or immobilization
– Recent surgery, particularly of the legs,
pelvis, abdomen, or chest
– Leg or pelvic fractures or injuries
– Use of high-estrogen oral contraceptives
– Pregnancy
– Chronic atrial fibrillation
21-65
Pulmonary Embolism
• Assessment findings and symptoms
– Sudden onset of dyspnea
– Apprehension, restlessness
– Possible pleuritic chest pain
– Possible cough
– Increased respiratory rate
– Increased heart rate
– Possible blood-tinged sputum
– Possible hypotension
21-66
Pulmonary Embolism
• Emergency care
– Position of comfort
– Give oxygen
– Transport
21-67
Acute Pulmonary Edema
• Most commonly due to failure of the heart’s
left ventricle
• Other conditions can result in pulmonary
edema, including
– Drowning
– Narcotic overdose
– Trauma
– High altitude
– Poisonous gases
21-68
Acute Pulmonary Edema
• Assessment findings and symptoms
– Restlessness, anxiety
– Dyspnea on exertion
– Orthopnea
– Paroxysmal nocturnal dyspnea
– Frothy, blood-tinged sputum
– Jugular venous distention
21-69
Acute Pulmonary Edema
• Emergency care
– Position of comfort
– Give oxygen
– Transport
21-70
Spontaneous Pneumothorax
• Does not involve trauma to the lung
• Two types
– Primary spontaneous pneumothorax
– Secondary spontaneous pneumothorax
21-71
Spontaneous Pneumothorax
• Assessment findings and symptoms
– Sudden onset of chest pain on affected
side
– Shortness of breath
– Increased respiratory rate
– Cough
21-72
Spontaneous Pneumothorax
• Emergency care
– Spinal stabilization if suspected spinal
injury
– Establish and maintain an open airway
– Give oxygen
– Transport
– Reassess often
21-73
Metered-Dose Inhalers
21-74
Metered-Dose Inhalers
21-75
Metered-Dose Inhalers
• An EMT can assist a patient in taking a
prescribed inhaler if all of the following
criteria are met:
– Patient has signs and symptoms of a
respiratory emergency
– Patient has a physician prescribed
handheld inhaler
– No contraindications to giving the
medication
– Specific authorization by medical direction
21-76
Questions?
21-77