Safety First: Advanced Breathing

 


Study Notes:

  1. 1.Know the ABCDEFG mnemonic for assessing someone’s breathing.  Know what to look for and what it means:
    A = Accessory muscle use
    B = Breath sounds
    C = Condition of skin (or complexion)
    D = Dyspnea (word dyspnea)
    E = Extending position
    F = Finger (SpO2)
    G = Gas (EtCO2)
    H = Heart Rate
    I = insp/exp ratio

  2. 2.Know the words we use to describe breathing:
    Eupnic (breathing well)
    Dyspnic (breathing poorly)
    Orthopnic (dyspnea while supine)
    Tachypnic (breathing fast)
    Bradypnic (breathing slow)
    Hypernic (breathing deep)
    Apneic (not breathing)

  3. 3.Know the different breathing patterns:
    Cheyne-Stokes 
    Biot’s
    Apneustic
    Kussmaul’s


  4. 4.Know the different breath sounds:
    Normal bronchovesicular
    Wheezing
    Ronchi
    Pleural Rubs
    Crackles
    Stridor

  5. 5.Know how to describe when and where the different breath sounds occur:
    Height
    Symmetry
    Phase


“Secondary Breathing”

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“Safety First” ... Table of Contents

Safety    Use your BSI - Biological Safety

              F is for Fire - Scene Safety

I                 I is for Incident: MOI/NOI          

R                Determine the numbeR of patients

S                Send for help

T                Trauma to the C-spine?

G                General impression of the patient

E                Estimate LOAs

T                Threats to you or your patient?

1°A             1° Airway

1°B             1° Breathing

1°C             1° Circulation

1°D             1° Decision

2°A             2° Airway

2°B             2° Breathing

2°C             2° Circulation

2°D             2° Decision

Heavy Breathing

In the secondary B section, we use some technology, but mostly some carefully developed clinical skills to assess how well the patient is breathing.

Knowing if someone is breathing well can be a difficult clinical decision.  To help my students learn and remember how to make this decision I’ve come up with another alphabetic mnemonic.  (Yay. Another mnemonic).  This one is ABCDEFG:

A stands for ‘Accessory Muscle Use’ (AMU).  How much ‘work-of-breathing’ (WOB) is the patient doing?  Check out their: intercostal indrawing, exaggerated chest wall movement, supraclavicular indrawing, platismal flaring, nasal flaring, anxious expression. 

B stands for ‘breath sounds’ and it reminds you to auscultate the lungs. 

C stands for complexion, and it reminds you to look at the patients skin condition – especially their skin colour - and the expression on their face.

D stands for dyspnea.  But it’s a particular type of dyspena.  Specifically we want to know ‘word dyspnea’, which is how many words the patient can say in one breath.  Anything under about 5 is bad.  This patient has ‘two word dyspnea’

E stands for ‘extending’ and it reminds to look to see if the patient is in tripod position.  We talked about this on the patient positions page.

F stands for ‘finger’, and it reminds you to put on the pulse oximeter.  I can’t go into detail here about this important tool, but usually, it should be above 95.  Anything under 90 is a panic value.

G stands for gas.  If you have the ability to measure end tidal CO2 in a non-intubated patient, you should do this for every patient who appears short of breath. Again, this is a huge topic, and an under-utilized tool in emergency medicine in general (even in ERs), so I can’t address it properly here but I urge you to study up on it and push for it in your service if you don’t already have it. 

H stands for heart rate.  Usually people who are hypoxic are tachycardic - look for heart rates above 100.  Later on, hypoxic patients brady down, so late hypoxia can present with a sinus brad.  Sometimes down in the 20’s or so.

I stands for inspiratory - expiratory ratio (or i/e ratio).  That means the comparison between how long it takes to breath in and how long it takes to breath out.  Normally it takes twice as long to breath out as it takes to breath in (remember, exhalation is passive), so the normal i/e ratio is 1:2.  This changes depending on the disease processes present.  In asthmatics (who have trouble breathing out) the i/e ratio becomes more like 1:3 or 1:4, with long, laboured, wheezy expirations.  In pulmonary edema it’s the opposite.  It takes work to get air into the fluid filled alveoli, so breathing in is difficult and the i/e ratio can change to 1:1.  So paying attention to the i/e ratio (which you can see from across the room) is a good clue to what is happening in your patient.

This mnemonic not only gives you a focused tool for assessing the short of breath patient, it also gives you a sequential order for reporting your findings.  Here’s a nice medic report:

‘Patient has gross accessory muscle use, wheezing audible without auscultation, pale skin, anxious, 2-3 word dyspnea, in tripod position, beginning to sag, 89% with non-rebreather at 15L and end tidal of 63 with bronchospastic wave form, he’s tachy at 118 and has a 1:3 i/e ratio’.

That really paints the picture, doesn’t it?  Try this one.

‘Patient is eupneic (see below) with no adventitia or respiratory distress, no word dyspnea in relaxed position, satting 99 on room air with a normal-wave end tidal of 37, heart rate 70 with normal i/e ratio’.

‘Sweeeet’!

Auscultation is an art best learned with a stethoscope in your ears and an experienced clinician beside you, but I’ll do the best I can just using text.  There are lot’s of sites on the internet that have sound files of different adventitous sounds that you can listen to which will help you to learn to recognize them.

Too many medics give terrible reports on their auscultation - mostly because they’ve never had a clear description of what they’re supposed to report.  So let’s talk about how we auscultate breath sounds.

First of all it helps to get an overall idea of the pattern of a patients breathing.  There are a few ‘med-speak’ words we use to describe this. The first group of words refer to the rate and depth of ventilation.

The first is ‘eupnic’ – a wonderful word which means they are breathing easily and normally (eupnea), as opposed to dyspnic, which means their having trouble breathing (dyspnea), and orthopnic which means they’re having dyspnea while supine (orthopnea).

If the patient is breathing fast we say they are ‘tachypnic’, (they have tachypnea) which is different than if they are breathing very deeply, which is called hyperpnea, we would say that they are ‘hyperpnic’. 

A patient can be both tachypnic and hypernic, and this is the true definition of the word ‘hyperventilation’, which is often incorrectly used to describe tachypnea with shallow ventilations.

If a patient isn’t breathing at all we describe them as apneic.

The next four words describe the actual pattern of breathing.

Cheyne-Stokes respirations have a pattern of apneic periods with sets of respirations occurring regularly.  At first the ventilations are shallow for a few breaths, then they get deeper, then shallow again for a few more breaths, and then another period of apnea. 

Biot’s respirations are regular, rapid, deep gasping breaths that also occur in sets with a period of apnea between them.

Apneustic respirations have a long inspiratory phase, with a short, sighing expiratory phase. 

Finally, Kussmaul’s respirations are tachypnea and hyperpnea together with no apneic periods.  This is another word for describing hyperventilation.  Unlike Cheyne-Stokes, Biot’s and Apneustic respirations - which are usually caused by CNS lesions - Kussmaul’s respirations are caused by having too much acid in the body, usually due to conditions like renal failure, diabetic ketoacidosis, or any other conditions that cause metabolic acidosis (you can use the mnemonic MUDPILES to remember these - google it if you don’t know it.)

After we look at the rate, depth and pattern of their breathing we want to search for adventitia.  This is the medical word for ‘bad breathing sounds’.  Although it’s difficult to describe sounds in writing alone, I’ll try my best. Fortunately you can easily find dozens of free websites that will play recordings of adventitia.  Just google ‘adventitia’ or ‘breath sounds’.

First of all, the best part of the chest to listen through is the back.  Usually it has less muscle and less hair.  You should always try to put your stethoscope directly on the patient’s skin, even if you have to stick your hand up, (or down) their sweater to do it.

Invariably we listen with our stethoscope (auscultate) for adventitia, but some adventitia is audible even without a stethoscope.

Normally we should hear clear breath sounds over the large airways in the middle of the chest that kind of sound like someone breathing heavily through their nose right up close to a microphone.  These are called bronchial sounds.

Out towards the edges of the chest, over the smaller airways, we’ll hear more gentle sounds that sound like someone blowing on a microphone through their mouth from about a foot away.  These are called vesicular sounds.

If the bronchial and the vesicular sounds are nice and clear, just the way I’ve described them, then we say the patient has normal bronhcovesicular breath sounds.  That is how a normal patient with no ventilatory pathology sounds.  However, many of our patients aren’t like this – they often have something going wrong with their breathing.

One of the most common adventitious breath sounds is wheezing.  If you’ve ever cared for an asthmatic patient you will have heard this distressing noise which is high pitched, almost musically resonant sound.  Early wheezing is usually expiratory, as it gets worse you’ll hear inspiratory and expiratory wheezing.  When they get really bad, the wheezing will stop.  This is a very bad sign.  Asthmatics in severe respiratory distress should be wheezy, if they aren’t we call them a ‘silent chest asthmatic’, and it means they are about to crash (if they haven’t already).

Smokers and other patients with chronic obstructive pulmonary disease (COPD) often have continuous, low pitched, snoring-like sounds that often clear with a cough.  These are called ronchi (‘wrong-KI’).

Pleural rubs are a relatively rare adventitious sound that indicate the pleural layers of the lungs are rubbing together.  These patients will almost always have a lot of pain associated with breathing.  You can reproduce this sound easily by holding the end of your stethoscope in a closed fist and then rubbing your knuckles together.

Crackles are a very common adventitious breath sound and they are divided into coarse and fine crackles.  Course crackles sound like scuba bubbles when you’re under water.  Fine crackles sound like wood popping as it burns in a fireplace.  Be careful when you hear crackles because there is a relatively rare finding called ‘mediastinal crunch’ (or Hamman’s sign) which are crackles that synchronize with the heart rate, not with breathing, and are due to pneumomediastinum. 

Stridor is sometimes confused with wheezing, but it’s different.  Wheezes come from in the chest whereas stridor comes from the throat.  It’s caused by a partial obstruction of the airway.  If you ever see a paramedic auscultating a patient’s neck, it’s because they are trying to differentiate stridor from wheezes.  However, stridor is usually very evident, even without auscultation.


After we’ve sensed the pattern of the patient’s breathing and auscultated for adventitious breath sounds we have to describe where and when that adventitia occurs.

First we describe how high and low the sounds are in the lungs (the height).  If the adventitia is just in the bottom of the lungs we describe it as ‘basilar’.  If it goes higher we often describe how high it goes in reference to the scapulas – low-scap, or mid-scap.  If it goes above the scapula we describe it as apical, or we can say it is in the apicies.

Next we describe the location in terms of right and left - their symmetry.  Occasionally adventitia is in one side or the other, but often it is in both, which we describe as being bilateral.

If the breath sounds are all throughout the lungs – right and left, top to bottom – we describe them as being ‘global’.

Finally, we want to describe whether the adventitia occurs during inspiration (inspiratory), expiration (expiratory) or both (in which case we say ‘inspiratory-expiratory’ and chart as ‘i/e’).  This is referred to as the phase.


So, a proper report of the auscultation of a healthy patient might sound like this:

‘Eupneic with normal bronchovesicular sounds, no adventitia.’


A proper report of the auscultation of an asthmatic might sound like this:

‘The patient is tachypneic with fine, global, early inspiratory wheezes’


A proper report of the auscultation of a patient with pulmonary edema might sound like this:

‘The patient is hyperpneic with coarse, bibasilar inspiratory expiratory crackles to the mid scaps’.


Practice listening with these points in mind and, if you have the chance, try to listen to how physicians give auscultation reports to other physicians.  Even if you don’t get a chance to give a full verbal report of your auscultation, you should chart it in detail following this outline.

So knowing how to instantly recognize a patient in respiratory distress, including how to auscultate thoroughly, and attaching and interpreting your oxygen saturation and end tidal CO2 monitors is the key to the 2°B step.

Now let’s ‘C’ what comes next (nyuk nyuk) ...