Respiratory Distress

Shortness of breath is a common complaint encountered by the EMS provider. We often hear it as part of a litany of other S/S or as a primary chief complaint. In either case SOB is never to be taken lightly and its causes should always be thoroughly investigated. My desire with this article is to give you some tips on how to streamline your treatment and formulate your thoughts as to how to proceed.

There are, in my opinion, two types of shortness of breath. I classify them as Primary SOB and Secondary SOB. You probably will not find these terms in the text book but if you follow my logic I believe you'll find these definitions helpful in formulating your treatment plans.

Primary SOB is caused by some sort of lung disease or disorder. The cause is located in the lung. Some of these causes would be PE, asthma, emphysema, bronchitis, pneumonia, etc. Trauma directly to the lung might also be included in this category. In these cases the treatment is directed at fixing the primary problems in the respiratory tract. An example would be the use of bronchodilators to open the lungs in a patient suffering from an asthma attack.

Secondary SOB is the body's response to an event not primarily involving the respiratory system. Examples of this would be SOB secondary to a heart attack, CHF, anxiety attack, blood loss, exercise, anaphylaxis, or substance/chemical abuse. While these events may include treatment for the respiratory tract the primary goal is to resolve the initiating event, such as calming the patient to reduce hyperventilation. A typical example of this would be a patient complaining of SOB as their primary symptom. However during your exam you discover that their SOB increases when they lie down and they can only sleep sitting up. Even though the SOB is their C/C their other "lesser complaints" should lead you to conclude that CHF may be the primary cause for their symptoms. If this were the case we would want to address those causes for the backup of fluid in the lungs.

In all cases the EMS team is responsible to respond to the needs of the patient. Hypoxia, regardless of the source needs to be vigorously addressed. The lungs need to be opened or cleared as determined by the physical exam. The cause of the SOB needs to be determined and addressed.

The treatment modalities are often "cause specific" not symptom specific. For instance; a person who complains of SOB due to his asthma is best treated with bronchodilators and O2. The source of his problem is in the lung itself. If we open the lung fields the problem is resolved. On the other hand, a person who presents with a C/C of SOB and is determined to have pulmonary edema secondary to CHF would most likely be treated with O2, Nitro, Morphine and Lasix. The SOB is secondary to the CHF. Treating with bronchodilators would provide only limited, if any relief. Removing the fluid from the lungs and correcting the cardiac problems is the ultimate goal in this situation.

The keys to determining the nature of the SOB are the time tested basics. The initial patient interview must be done quickly and will include the patient's name, age, C/C, including the nature of the onset (sudden or gradual), the intensity and the duration of the event. Follow this up by ruling out other complaints the patient may have but would not readily tell you or that they themselves might not recognize as important. The only way to get this information is to ask specific questions designed to rule out the presence of other signs and symptoms which would be of concern to you. This means taking control of the interview long enough to ask these questions in a yes and no answer format.