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.
An example would be "are you nauseous" or "did you break out into a sweat?" I have had many patients complain of SOB and not mention the sudden onset of weakness and nausea which accompanied the SOB. They were distracted by the SOB and did not realize the other complaints could be related and significant. The final question in the initial interview will be the history of the current C/C. Here again I always ask if the onset was sudden or gradual. Sudden events should concern us until we can identify their cause. The initial patient interview in which the C/C is SOB should lead you to the need for some form of oxygen therapy. In the patient with a shortness of breath complaint we are safe giving the appropriate levels O2 as an initial intervention before completing a full and extensive physical exam.
Once the initial interventions are administered the EMS team must do a complete patient survey along with a full interview to determine the history of the event. Be aggressive in your questions and ask them in such a way as to acquire the information you need. Be specific. Is the onset sudden or gradual? Does position make a difference? Have they felt this way before? Are the symptoms classic or subtle? If they are subtle, can you rule out any thing of importance? The interview is often the only thing that will lead you to a correct solution. Along with the interview we must endeavor with our technology to rule out as many causes as possible to determine if the complaint falls into the Primary or Secondary SOB category. Twelve lead EKG's, SPO2 and SPCO values, blood sugar values, and a full appropriate physical exam are necessities for this evaluation.
Treatment for Primary SOB is fairly straightforward and can produce relatively quick results. Unfortunately, there are times when we treat secondary SOB as though the only symptom worth treating is the SOB or the improvements from oxygen therapy lull us into believing we need not look for or treat other symptoms which are causing or fueling the problem. This can be dangerous for the patient especially if we resolve the SOB and the patient then feels no need to seek further evaluation. My point here is that all SOB complaints need to be thoroughly evaluated and all suspected causes identified and addressed. This generally means a trip to the ED for more extensive evaluation than we can provide in the field.
I hope you find this helpful in some way as you deal with the SOB patient.
Jim Baird is the Fire Chief for the City of Brunswick Fire Department in Ohio. He is a Certified EMS instructor and also serves as a Certified Fire Instructor for Cuyahoga Community College Fire Training Academy. He is retired from the Mesa Fire Department in Arizona where he served as Firefighter Paramedic/Captain Paramedic for 20 years. He has 29 years of experience in the emergency services. You can contact him via E-mail at JBaird@brunswick.oh.us or Bairds2468@sbcglobal.net.