Dyspnoea & Respiratory Distress

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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

Risk Assessment

	Normal	Mild Distress	Moderate Distress	Severe Distress (Life Threatening)
General Appearance	Calm, quiet	Likely to be calm, may be mildly anxious	May be distressed, anxious	Distressed, anxious, fighting to breathe, exhausted, altered conscious state
Speech	Clear and steady sentences	Speaks in sentences	Speaks in short phrases only	Only 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 - 15	15 - 20	> 20	> 20 or < 6 - 8
Respiratory Rhythm	Regular and even	Asthma: may be slightly prolonged expiratory phase	Asthma: prolonged expiratory phase	Asthma: prolonged expiratory phase
Breathing Effort	Little with small chest movements	May be slight increase in normal chest movement	Marked chest movement and may have some use of accessory muscles	Marked chest movement with accessory muscles, intercostal recession and/or tracheal tugging
Pulse Rate (per minute)	60 - 90	60 - 90	Tachycardia (100 - 120)	Tachycardia >120 or Bradycardia <60
Skin	Normal	Normal	May be pale and sweaty	Pale and sweaty, and be cyanosed
Conscious State	Alert	Alert	May be altered	Altered 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.

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)

Manage as per CPG:
Treat airway obstruction
Consider cardiac monitor
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

Critical & Extended Care (CCP, PSO)

Additional Information

References

Key Terms & Links

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Responsible Manager

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