Assessing Respiratory Distress

One of the first things they teach you in EMT school is that air should go in and out. So when patients report feeling short of breath, it's time to get serious. Differentiating between the many cases of respiratory distress is far from simple, but using your clinical acumen, being diligent and paying attention to detail can lead you down the path to the right conclusion, facilitating the right treatment plan and doing right for the patient.

First, remember that shortness of breath can be primary or secondary. That is, something might be wrong with the lungs or elsewhere, prompting the lungs to compensate. Primary problems would include asthma, COPD, pulmonary edema, anaphylaxis, pneumonia, pleural effusion and pneumothorax. Secondary problems would include metabolic acidosis, stroke, head trauma, toxicological overdose, sepsis and diabetic ketoacidosis. Figuring out which path to go down requires a careful physical exam, including vital signs, the incident history and patient symptoms.

PHYSICAL EXAM

Focusing on the lungs, auscultation is key. Crackles aren't just crackles, and wheezes aren't just wheezes. Crackles that are coarse, thick and sound "junky" can indicate mucus or infection, while crackles that are fine and "gurgley"-sounding can indicate edema. Wheezes indicate bronchoconstriction, but not necessarily from asthma or COPD. A cardiac wheeze brought on by heart failure is probably more common than we realize, and is often misinterpreted by EMS providers (and emergency physicians, for that matter). Careful, purposeful auscultation is key to understanding what is wrong with your patient and how you can fix it. To get more clues from auscultation, listen intently with your stethoscope on the patient's skin at the left and right apex, hilum and bases.

Air goes in and out, but when is extra respiratory effort required? The inspiratory and expiratory phases of respiration can shed more light on why your patient is in distress. Is your patient working hard to breathe in or trying to force air out? Inspiratory problems are likely caused by compliance pathologies, like pulmonary edema and pneumonia, while expiratory problems are likely caused by resistance pathologies, like asthma and emphysema. Of course, some pathologies are mixed: Anaphylaxis creates mucus that requires more inspiratory effort, as well as bronchoconstriction, which requires increased expiratory pressure. Just staring at the chest to see which phase of respiration is delayed may be a valuable exercise that enlightens your clinical decisions.

Other clues on physical exam include signs of cardiogenic right-sided heart failure, like JVD, ascites and peripheral edema. But remember that these are also signs of cor pulmonale, which is right-sided heart failure caused by pulmonary hypertention, usually the result of lung pathologies like COPD. Further, in flash cardiogenic pulmonary edema, the left heart failure leading to edema may not have affected the right side of the heart just yet, so these signs may be absent altogether. It's important to conduct a careful physical assessment, as your treatment decision could teeter on your findings.

INCIDENT HISTORY

The usual OPQRST works well here, along with a careful understanding of past episodes of shortness of breath. Has this patient been hospitalized for such? Intubated? Does he sleep with CPAP? Does he take his puffers every once in awhile, or every day? Is his chest pain in addition to the breathing problem? Has he had any air travel, operations, or pain in his calves? What about exposure to sick people, hospitals, nursing homes or daycares? Is he compliant with his medications, and have the medications been changed at all recently? The answers to these questions will start to paint a picture that can guide you to the right conclusion.

VITAL SIGNS