Breathing part 3

A patients’ breathing can be affected by several medical and traumatic events. The overall aim is to ensure that the patient has adequate and effective respirations/ventilations. This may be done through assisting ventilations, mechanically ventilating, or through drug treatment.

Respiratory arrest – For several medical or traumatic reasons, a patient may be in respiratory arrest. This is where the patient is making no respiratory effort, and no air is entering or exiting the lungs. A Bag Valve Mask (BVM) is needed to ventilate the patient. Follow a stepwise airway approach to ensure that the patient is getting adequate and effective ventilations. Ventilate the patient at a rate of 10 ventilations per minute, or a ventilation every 6 seconds. Be wary of the volume of ventilation when ventilating a patient with a BVM, over-ventilating the patient or being heavy handed with the BVM could cause potential barotrauma of the lungs.

Respiratory distress – Some medical or traumatic cases may cause a patients’ respiratory rate to be too high or too low, affecting their ability to ventilate their lungs adequately and effectively. If your clinical judgement feels that this respiratory effort is ineffective, then you may need to support the patients’ breathing with a BVM.

SPO2 – In some cases, a patients’ SPO2 may be low due to the medical or traumatic event ongoing. Supplemental Oxygen may be required via a face mask to support and normalise their SPO2 levels. Clinical judgement is required as per what face mask is used and how much is applied to reach the desired SPO2. In cases of major/critical trauma, patients should receive 100% Oxygen via facemask. This is to help alleviate some of the negative processes that occur in a patient with critical traumatic injuries.

Oedema – In some events, fluid/oedema may collect in the lungs creating a barrier between the air and the walls of the alveoli. This makes gaseous exchange difficult as the Oxygen and Carbon dioxide have to try and diffuse through the fluid to reach the cell membranes. The presence of oedema is usually indicated through auscultated crackles, frothed sputum, and/or an audible ‘bubbling’ on the chest. Patient positioning can help alleviate the immediate difficulty in breathing by oedema through sitting them up in an upright position. Further treatments, such as medications, may be required to provide greater support to the patients’ breathing.

Asthma – An inflammatory disease of the airways associated with episodes of reversible over-reactivity of the airway smooth muscle. Asthma can range from mild to life-threatening, and usually requires medication to treat. Within the UK, nebulised Salbutamol is initially administered to ease the effects. If this fails, then nebulised Ipratropium Bromide is also administered. In severe cases, hydrocortisone can also be administered. In life-threatening asthma, failing nebulisation, Adrenaline 1:1000 IM can be administered, followed by Hydrocortisone. If respiration fails, then supportive means via BVM may be required whilst rapidly transporting to hospital.

COPD – Chronic Obstructive Pulmonary Disease (COPD), the long-term pathophysiological condition covering Pulmonary Emphysema and/or Chronic Bronchitis. Sufferers can have episodes where ‘flare ups’ cause difficult/distressed breathing due to new infection, agitation of the airway, etc. The effects of COPD can range depending on the individual, their general health, age, the stage of the disease, and surrounding circumstances. During an exacerbation episode, Salbutamol nebulisation treatment can be given to alleviate the condition. If this fails, Ipratropium Bromide nebulisation can be given. When nebulising, limit administration to 6 minutes. If journey time to hospital is significant consider a further 6 minutes of nebulisation. This is due to some COPD patients being chronically hypoxic due to the condition, and when given Oxygen, may cause adverse effects to their respiratory drive. Due to this also, SPO2 target saturations should be between 88-92% when looking at Oxygen administration and management. If respiration fails, then supportive means via BVM may be required whilst rapidly transporting to hospital.

Pulmonary Embolism (PE) – A PE consists of a clot forming in one of the lungs, potentially affecting a large area of tissue and gaseous exchange. Symptoms can include sudden shortness of breath and chest pain. The Wells criteria can assist in identifying the risk likelihood of the event being a PE. Treatment is limited in the pre-hospital environment requiring Oxygen therapy to maintain SPO2 levels and transport to hospital. If respiration fails, then supportive means via BVM may be required whilst rapidly transporting to hospital.

Heart Failure – Heart failure is a circulatory issue, however, it can cause pulmonary oedema to collect in the lungs causing difficulty in breathing for the patient. Symptoms can present with difficulty in breathing, crackles, ‘bubbling’ on the chest, and pink frothy sputum. Treatment involves administering Oxygen, Glyceryl Trinitrate (GTN), and Furosemide. If respiration fails, then supportive means via BVM may be required whilst rapidly transporting to hospital.

Pneumothorax/Haemothorax – Where either through trauma or medical means a pocket of air or bleeding forms within the pleural space, causing the lung to collapse. A pneumo/haemothorax will cause the patient to feel difficulty in breathing. Oxygen may be required to help treat any hypoxia and the patient will need urgent care at a hospital. If the pocket of air continues to exert greater pressure on the lung and thoracic structures, a tension pneumothorax can form. Treatment required for a tension pneumothorax includes Oxygen and a needle thoracocentesis. This involves penetrating the chest wall with a needle in the mid-clavicular, 2nd intercostal space, just above the 3rd rib. Many different ambulance services have specialised equipment for aiding in this. If respiration fails, then supportive means via BVM may be required whilst rapidly transporting to hospital.

Chest injuries – Chest injuries can present in many different forms. Broken ribs may require analgesia to help manage pain and make it easier for the patient to breath. A sucking chest wound will require a non-occlusive dressing placed over it. A flail segment of the chest can cause difficulty in breathing and the patient may require BVM support. If SPO2 levels are abnormal then further Oxygen is required. If respiration fails, then supportive means via BVM may be required whilst rapidly transporting to hospital.