Welcome to another “What Paramedic Do” – where we delve into what we actually do for patients with various complaints. Today it’s the super common “short of breath” or “can’t breathe” or whatever you’d like to call it.
What is dyspnoea?
“Dyspnoea” is the medical term for difficulty in breathing. There are all kinds of subjective and objective measures of dyspnoea – from what the patient tells us to what we observe or hear. The causes of dyspnoea are myriad – and part of our job is to figure out what the potential cause is, and see if we can reverse it. I’d say that most times when I get called to a dyspnoea case, it’s benign and not critical. But air going in and out is one of the most important parts of our physiology, so we take very case seriously.
What are some of the causes? I’ll go through the most common ones:
- Asthma or Chronic Obstructive Pulmonary Disease (COPD): COPD encompasses emphysema and chronic bronchitis (both predominately seen in older patients secondary to tobacco smoking), and is lumped together with asthma. In both cases, the patient has trouble breathing out because the airways become narrowed or blocked with mucous. Air gets trapped down in the lungs and they stop ventilating properly.
- Pneumonia or chest infections. If an infection gets down into your lung, the inflammatory response will activate to try to kill it. This can produce mucous, pus and other gunk that fill up the alveoli – the little air sacs where gas exchange occurs.
- Pain. If you have quite bad chest pain, you’ll have trouble breathing. I’ll do an article on chest pain some other day, but the reasons for chest pain are quite varied.
- Heart Failure. This is more prevalent in the elderly, who have hearts that can’t keep up anymore, usually due to previous heart attacks (myocardial infarctions). This causes fluid to back up into the lungs since it has nowhere else to go, and thus infiltrates and collapses the alveoli.
- Anxiety-related (or psychogenic) – panic attacks, anxiety events, that sort of thing
- Vomiting – I don’t understand why I have to mention this, but you have trouble breathing when you vomit because your body is guarding your airway. Vomit getting into your lungs can be a death sentence (called aspiration and kills a load of heroin overdoses, assuming the whole ‘not breathing’ thing doesn’t get them first). When you vomit, your body will deliberately close off your airway to stop anything getting down there. Are you having trouble breathing when you vomit up that dodgy chicken? Yes – but we’re not going to fix or change that, because it’s supposed to be that way.
There are a few other less common but life threatening causes:
- Pulmonary Embolism – a blood clot in the lung. If it’s big enough it can kill you easily. Obviously blocking blood to the lungs is bad – it means that any air getting down there is totally wasted, because there’s no blood to go past it and exchange oxygen and carbon dioxide. Anybody can get a PE, and sometimes they present atypically (not like the textbook). Sometimes all anybody gets is a sudden onset shortness of breath, but they usually get sharp chest pain too.
- Pneumothorax – or a collapsed lung. This can happen spontaneously (e.g. without a traumatic cause), particularly in tall and thin males.
- Foreign body airway obstructions – basically, choking on something. That piece of grade A German sausage can lodge in your airway and ruin your day. Note that you don’t choke on liquids, you drown in them. If you accidentally inhale some of your Mountain Dew, will you feel like you can’t breathe? Yes, because you’ll be coughing to try to get rid of it. Will it kill you? Not unless you shoved the whole bottle down there.
- To compensate for something else. In a patient is in shock for example (that is, poor blood flow around the body, not like ‘I’m shocked at these prices!’), then they will breathe faster to try to maximise oxygen delivery to what blood is still circulating. Similarly, if the patient is in an acidotic state (that is, their blood’s acidic, as can be seen in some diabetic or metabolic conditions), they will breathe faster to blow off carbon dioxide, and thus some of that acid.
- Trauma. Obviously, if you get shot in the chest, you’re going to have trouble breathing.
- Anaphylaxis – or a major allergic reaction to some sort of stimulus, like a bee sting or peanuts.
How do we assess?
The first thing we want to know is are you ventilating effectively? This simply means whether or not you’re moving adequate amounts of air – whether you have an adequate respiratory rate and tidal volume (or depth of breathing). If you don’t, we need to ventilate you – and you’re probably unconscious and can’t fight us. We also get a general overview of your appearance and speech – if you’re sitting upright, don’t appear distressed and are able to speak in full sentences, you’re okay.
Next we’ll start assessing. We have a few ways to do this:
- We’ll listen to your chest with a stethoscope – listening for the sounds in your lungs. We’ll listen for wheezes, crackles, other noises, and equality of air entry. This gives us an idea of what the airways are doing and how much air is getting through the lungs.
- Vital signs. We take a full set of vital signs on every patient. Part of that is pulse oximetry, where we put a probe with a red light on one of your fingers. This shines the light down into the capillaries and watches the reflective signal – which indicates the amount of haemoglobin saturated with oxygen as a percentage. Over 94% is good for most people. Where it’s low, we look at giving you oxygen. It isn’t the end-all and be-all of vital signs though; we look at your heart rate, blood pressure, often your ECG, and temperature to build up a clinical picture.
- We’ll also do a head to toe to look for potential causes. If we see swollen feet in an elderly person (called peripheral oedema) we can guess that their cardiac function is impaired and it might account for their shortness of breath. The signs and symptoms are too numerous to mention here, but there’s lots of things we’ll look for to identify a cause.
- We’ll also obtain a history and ask you about your shortness of breath, what you were doing at the time, whether you’ve had it before and how it compares, whether you smoke, and so on. It’s important to be honest – we don’t really care if you smoke weed and it triggers your asthma, we only care that you’re honest about it.
How do we treat and transport?
In most cases, the feeling of dyspnoea is fairly minor and patients are ventilating and oxygenating adequately. Thus in most cases there isn’t much for us to do except transport if required. Otherwise, treatment largely depends on the cause.
- If it’s traumatic, we need to manage the injury. A penetrating wound gets a chest seal to stop air getting in via the wound and collapsing the lung. If air gets trapped in the chest cavity, we may have to decompress the chest using a long needle to allow that air to escape. If it’s just pain, we manage the pain.
- If there’s an airway obstruction, we try to clear it. This is done with back blows or chest thrusts (the same as in first aid!) until you go unconscious – then we get out a laryngoscope and a big set of forceps and look down your airway to retrieve it.
- If we go to an asthma/COPD case, or a case with a degree of bronchospasm (narrowing of the airways producing a wheeze), we can give drugs like salbutamol (Ventolin) and ipratropium (Atrovent) to open them up. We give these by a nebuliser, which is a mask that turns the liquid drug into a mist that you inhale. Most patients who call with a bronchospasm will have one or two of these and will be okay. We can also look at hydrocortisone or magnesium in severe cases.
- In anaphyalxis or severe asthma/COPD that doesn’t respond to bronchodilators, we give adrenaline – usually intramuscular, but sometimes intravenously.
- Sometimes we use Continuous Positive Airway Pressure (CPAP) to help ‘splint’ the alveoli open; this involves putting a tight fitting mask on your face, which applies a bit of constant pressure. It can be a bit uncomfortable, but it works remarkably well. It doesn’t take over breathing, but assists your breathing – so long as you can tolerate it.
- Heart failure can be tricky to manage and involves a combination of nitrolingual spray and CPAP in most cases, along with rapid transport and correction of the underlying cause if possible.
- Oxygen is always a consideration but we don’t use it just because we have it. Oxygen treats hypoxaemia – low oxygen in the blood. If their oxygen saturations are reading over 94%, and they don’t need nebulisers, and there isn’t a condition that mandates oxygen use (like shock or carbon monoxide poisoning), then we typically don’t give it.
- If you’re anxious, we try to calm you down. We don’t make you breathe into a paper bag (it’s useless) and we don’t give you oxygen (you don’t need it).
What YOU can do:
So what should you do if someone has trouble breathing?
- If they’re NOT breathing, start CPR. Give rescue breaths if you want – but at the minimum start CPR. The reason is that a patient who isn’t breathing will probably arrest very soon, and the public are generally poor at identifying the difference between a respiratory and cardiac arrest. Doing CPR on a patient who is not breathing but still has a pulse probably won’t cause any important damage, and it might save their life.
- If they have an airway obstruction, try to clear it. In Australia this is done by back blows (a sharp blow to the back, between the shoulder blades) and chest thrusts (pushing hard on their sternum, like you would for CPR but with them sitting upright). If it still doesn’t clear, and they go unconscious, start CPR.
- But if they can still cough – encourage them to cough. Being able to talk, cough, or cry indicates some degree of airway clearance, so getting them to cough might let them clear it on their own.
- If they have any other problem, tell them to sit in whatever feels the most comfortable – this is usually the tripod position: sitting upright, leaning forward with hands on their knees. This allows the chest to expand to its maximum. If they want to lay down, be wary – especially if they are pale, grey, or cold and sweaty to touch (clammy).
- If they have asthma, assist them to find their Ventolin inhaler and let them use it as required.
- Call emergency services (000 in Australia)