The initial patient size-up
When assessing a patient suffering from respiratory distress, one of the first items of interest is the patient’s work of breathing. When first visualizing the patient to check for level of responsiveness, also try to determine how much difficulty the patient is having moving air. Is he positioning his body in a certain way? Is he pursing (squeezing) his lips together? Is he using other muscles to assist in breathing? What does his skin color look like?
In general, patients exhibiting these signs of distress are experiencing difficulty breathing. Finding a patient leaned over with his elbows on his knees is called “tripod position.” While there is not much in the way of research to indicate the physiologic mechanism for tripod position, it is nevertheless a frequent observational finding in shortness of breath patients.
Pursed lip breathing is another clinical finding often seen in cases of dyspnea. By breathing through tightly closed lips, a patient is able to increase the amount of pressure in the lungs which can have a “splinting” effect, allowing the air passages to remain open throughout the breathing cycle. Patients with chronic inflammation in the lungs may breathe through pursed lips regularly so an understanding of the patient’s baseline is important when looking for acute changes.
The term “accessory muscle use” refers to the use of muscles other than the diaphragm to aid in breathing. Ordinarily the diaphragm, a strong, flat muscle separating the thoracic and abdominal cavities, contracts during inspiration, creating negative pressure in the thoracic cavity and causing the lungs to pull air in from the outside environment. In patients experiencing respiratory difficulty, muscles in the neck and between the ribs assist in moving the chest wall to create more negative pressure in an attempt to normalize breathing. This will often be seen as “retraction” or pulling back of the spaces above the collarbones and between the ribs.
Finally, skin signs are an important indication of a patient’s respiratory status. Cyanosis, or skin with a bluish tint, may indicate that a patient is not receiving enough oxygen. The finding of cyanosis in the core of the body, central cyanosis, such as the lips is often a more significant finding than that of cyanosis in the extremities, peripheral cyanosis, such as the nail beds of the hands or feet. Cyanosis results when hemoglobin in the blood without oxygen bound to it circulates close to the surface of the skin and appears blue in contrast to the red of well-oxygenated blood.
Lung sound auscultation
In addition to the basic visual presentation of the patient assessment, lung sounds can provide insight into the cause of a patient’s difficulty breathing. Proficiency at assessing lung sounds is a skill requiring regular practice to learn and maintain competency. As a general rule, lung sounds should be listened to at the same location on both sides of the body before moving to the next location so that a given lung field or lobe can be compared on both sides. In cases of pneumonia or a lower airway obstruction, there may be different lung sounds at the same location on different sides of the body.
It is important to note that not being able to hear lung sounds is not the same as a patient having clear lung sounds. As such, it is important to get in the habit of listening to lung sounds on stable, healthy patients so that you are more likely to notice when a patient does not have clear, “normal” lung sounds.
In the case of Sam from the scenario, your partner stated “I can’t hear anything.” In a patient experiencing significant difficulty breathing or work of breathing, based on a visual assessment, this should be a red flag. In Sam’s case, it is highly likely that your partner cannot hear lung sounds because the patient is not able to effectively move air in order to produce lung sounds.
Assessment and treatment of the soccer player
You noted previously that Sam is having a difficult time breathing and appears lethargic. Since his coach does not know his medical history you tell Sam that you will need to ask him some questions, but rather than try to speak you want him to nod “yes” or “no.” While your partner puts the patient on oxygen, you ask if Sam has ever experienced breathing problems like this before. He nods “yes.” You ask if he has any allergies, he shakes his head “no.” You ask if he has asthma and he nods “yes.” You ask if he takes medication like an inhaler and he nods “yes.” You tell Sam that you are going to start him on a longer term version of his rescue inhaler and ask your partner to administer an albuterol nebulizer via mask.
As you continue with your assessment, you notice that Sam’s respiratory rate has gradually slowed down and he is sitting up straighter. When you listen to his lung sounds you hear wheezing throughout his lungs. His follow-up pulse oximetry reading is 95 percent and he is able to answer your questions four to five words at a time. You recommend to Sam and his coach that he be transported to the emergency department and they both agree. You plan to contact Sam’s parents by telephone during transport to the hospital.
