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Quick Chart
Introduction
  • Dyspnoea and respiratory distress is difficulty in breathing or shortness of breath. It is a sign of a variety of disorders and is primarily an indication of inadequate ventilation or of insufficient oxygen.

Read the complete article; Dyspnoea in the Medical Library > Pathophysiology.

Clinical Presentation
  • Shortness of breath
  • Hypoxemia
  • Cyanosis
  • Tachypnoea
  • Tachycardia
  • Accessory muscle use/retractive breathing
  • Anxiety, progressing to drowsiness and confusion
  • Adventitious lung sounds:
    • Crackles
    • Stridor
    • Wheezing (note: wheezing in older persons may be due to acute cardiogenic pulmonary oedema and not asthma; patients themselves may make an incorrect assumption). Consider calling Clinical Support for advice.
Exclusion Criteria
Exclusion Criteria
Risk Assessment

NormalMild DistressModerate DistressSevere Distress
(Life Threatening)
General Appearance Calm, quietLikely to be calm, may be mildly anxiousMay be distressed, anxiousDistressed, anxious, fighting to breathe, exhausted, altered conscious state
Speech Clear and steady sentencesSpeaks in sentencesSpeaks in short phrases onlyOnly speaks in single words or unable to speak
Breath Sounds Usually quiet, no wheeze

May have a cough

Asthma:
Mild expiratory wheeze

May have a cough, stridor, crackles.

Asthma:
Expiratory wheeze, may also have a mild inspiratory wheeze

May be unable to cough.

Asthma:
Expiratory wheeze, may also have inspiratory wheeze. If severe may be no breath sounds

Respiratory Rate (per minute) 10 - 1515 - 20> 20> 20 or < 6 - 8
Respiratory Rhythm Regular and evenAsthma: may be slightly prolonged  expiratory phaseAsthma: prolonged  expiratory phaseAsthma: prolonged  expiratory phase
Breathing Effort Little with small chest movementsMay be slight increase in normal chest movementMarked chest movement and may have some use of accessory musclesMarked chest movement with accessory muscles, intercostal recession and/or tracheal tugging
Pulse Rate (per minute) 60 - 9060 - 90Tachycardia (100 - 120)Tachycardia >120 or Bradycardia <60
Skin NormalNormalMay be pale and sweatyPale and sweaty, and be cyanosed
Conscious State AlertAlertMay be alteredAltered or unconscious
  • Epiglottitis is inflammation of the tissue that covers the trachea.
    • It is a life-threatening disease and medical emergency.
    • Spasm may cause the airways to close abruptly.
    • Patients suspected of suffering epiglottitis should be handled with care.
    • Note: Sudden complete obstruction due to epiglottitis may respond to tipping the child steeply head down, and using back-blows to dislodge the swollen epiglottis.
  • Never stop oxygen if patient's level of consciousness or breathing deteriorates; oxygen almost never depresses breathing in the field and can usually be attributed exhaustion and fatigue (especially of the diaphragm). Exhaustion can depress breathing and/or level of consciousness, even if the patient is given oxygen.
  • Children with croup, epiglottis or laryngeal oedema who develop respiratory arrest usually do so as a result of exhaustion or spasm. You will still be able to ventilate gently with appropriate bag-valve-mask, mouth-to-mask or mouth-to-mouth.

Hyperventilation

  • Try to "talk down " the respiratory rate with or without the use of oxygen as a tool to help. If indicated as per the guideline, ensure that you administer oxygen using the appropriate mask to achieve optimal oxygenation.
  • Whilst hyperventilation is usually associated with severe emotional stress, do not over-diagnose "hyperventilation " in the field.  Your patient could have a pulmonary embolus or other serious problem. 
Management
Primary Care
  • Primary Survey
    • If respiratory distress caused by exposure to noxious substance, remove substance or patient if safe to do so. Assistance from Department of Fire & Emergency Service (DFES) or other appropriate resource may be required.
  • Position patient appropriately (sitting patient upright or in a position of comfort; lateral position if unconscious)
  • Reassurance (continuous)
  • Conduct Vital Sign Survey, particularly respiratory rate and pulse oximetry
  • Consider oxygen therapy; titrate SpO2 using the appropriate mask to a target of 94–98% for adults (88–92% for COPD patients) and at ≥ 95% for children.
  • Ventilate the patient if required
    • Newborn/Neonate: Manage as per Newborn Life Support in regards to ventilatory support/resuscitation
  • Consider Secondary Survey
Intermediate Care (EMT / Level 2)
  • If wheeze present, administer Salbutamol
  • If experiencing Anaphlyaxis, administer EpiPen
  • If experiencing chest pain of presumed cardiac origin, manage as per Acute Coronary Syndrome CPG
    • Note: Hyperventilation with chest pain is an Acute Myocardial Infarction until proved otherwise; manage accordingly.
  • Manage choking
  • Consider applying cardiac monitor if trained and authorised
  • Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
  • Transport Priority 1 if patient time critical, pre-notifying receiving facility
Advanced Care (AP)
Critical & Extended Care (CCP, PSO)
  • As per Advanced Care (AP) guidelines
Additional Information
  • Respiratory arrest
  • Cardiac arrest

References
References
Key Terms & Links
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