EMT · Primary Assessment · 6 min read
Breathing Assessment: Respiratory Distress and Failure
- Differentiate the normal parameters of breathing from abnormal rates, rhythms, depths, and work of breathing across adult and pediatric patients.
- Distinguish between respiratory distress and respiratory failure using clinical indicators including mental status, physical effort, and respiratory mechanics.
- Determine the appropriate BLS interventions, oxygen delivery modalities, and assisted ventilation rates for patients experiencing respiratory compromise or respiratory arrest.
Fundamentals of Respiratory Assessment and Ventilation Mechanics
A thorough breathing assessment requires an EMT to evaluate four essential components: rate, rhythm, depth, and effort. Under resting conditions, normal breathing should be effortless, quiet, and symmetrical, occurring without the use of accessory muscles. Adequate breathing requires both an adequate respiratory rate and an adequate tidal volume. Tidal volume is the amount of air moved into or out of the lungs in a single breath. Multiplying the respiratory rate by the tidal volume yields the minute volume, which represents the total volume of air moved through the respiratory system in one minute.
Normal resting respiratory rates vary significantly depending on the age of the patient. An adult's normal resting respiratory rate is 12 to 20 breaths per minute. Pediatric patients naturally breathe faster: a child's normal resting respiratory rate is approximately 15 to 30 breaths per minute, while an infant's normal resting respiratory rate is approximately 25 to 50 breaths per minute. When assessing rate, an EMT must identify abnormal deviations. Bradypnea is an abnormally slow respiratory rate, whereas tachypnea is an abnormally rapid respiratory rate.
Evaluating the quality of respiration requires careful observation of rhythm and depth. Breathing rhythm is clinically categorized as regular or irregular, while breathing depth is categorized as normal, shallow, or deep. Adequate breathing is marked by bilateral chest rise and fall that is symmetrical. In addition, an EMT must auscultate lung sounds bilaterally over the apices and bases to confirm air movement throughout the lungs.
A critical principle of respiratory mechanics is that shallow breathing directly reduces tidal volume. When a patient takes shallow breaths, a fast respiratory rate does not necessarily compensate for poor ventilation. Rapid, shallow breathing may provide inadequate ventilation even when total minute volume is normal or high, because a greater proportion of each breath remains in the airways rather than reaching the alveoli.
Common mistakes
- Relying solely on respiratory rate to judge breathing adequacy while overlooking shallow depth, which reduces tidal volume and may cause inadequate alveolar ventilation even when total minute volume is normal or high.
- Waiting for cyanosis of the lips or tongue to appear before intervening; cyanosis is a late sign of significant hypoxemia, and care must begin much earlier.
- Mistaking a slowing respiratory rate in a previously tachypneic patient for clinical improvement rather than recognizing it as respiratory muscle fatigue and impending failure.
- Overventilating patients with a bag-valve-mask by squeezing too rapidly or forcefully, which causes gastric distention and reduces venous return to the heart.
Key points
- Adequate breathing requires both an adequate respiratory rate and adequate tidal volume to maintain a sufficient minute volume.
- Normal resting respiratory rates are 12 to 20 breaths per minute for adults, approximately 15 to 30 for children, and approximately 25 to 50 for infants.
- Increased work of breathing is identified by accessory muscle use, retractions, tripod positioning, pursed-lip breathing, and pediatric signs such as nasal flaring, head bobbing, grunting, and seesaw breathing.
- Respiratory distress features increased work of breathing while ventilation may remain adequate; respiratory failure occurs when the system cannot maintain adequate oxygenation or carbon dioxide elimination.
- Altered mental status, diminished breath sounds, severe speech limitations, and slowing respiratory rates indicate decompensation into respiratory failure.
- Spontaneously breathing patients with adequate ventilation and significant hypoxemia receive oxygen via nonrebreather mask at 10 to 15 L/min; mild hypoxia in mask-intolerant patients is managed with a nasal cannula at 1 to 6 L/min.
- Respiratory failure with inadequate ventilation requires immediate assisted ventilation with a bag-valve-mask; give each breath over about 1 second, approximately every 6 seconds for adults with a pulse or every 2 to 3 seconds for children and infants with a pulse, following local protocol.
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