Essential Parameters of Airway

Evaluation: Ventilation
Lecture 6
 Rate, Regularity, and Effort
• The normal respiratory rate in a resting adult
is 12 to 24 breaths/minute.
• Regularity is defined as a steady inspiratory
and expiratory pattern.
• Breathing at rest should be effortless. It also
should be marked by only subtle changes in
rate or regularity.
• Patients in respiratory distress often
compensate for their inability to breathe
easily by sitting upright with the head tilted
back (upright sniffing position), leaning
forward on the arms (tripod position), or
lying with the head and thorax slightly
elevated (semi-Fowler position). These
patients frequently avoid lying flat, or supine.

Why would lying flat on the back (ie, in the supine

position) most likely worsen respiratory distress?
 Recognition of Airway Problems
• Respiratory distress may be caused by upper or
lower airway obstruction, inadequate
ventilation, impairment of the respiratory
muscles, ventilation/perfusion mismatch,
diffusion abnormalities, or impairment of the
nervous system.
• Dyspnea often is associated with hypoxia.
 Observation Techniques
• Visual clues can aid the recognition of airway
problems.
• Paramedics should note the patient’s preferred
position to facilitate breathing.
• They also should assess the rise and fall of the
patient’s chest.
• visual clues to respiratory distress include the
following:
• patient’s chest. Other visual clues to respiratory
distress include the following:
– Gasping for air
– Cyanosis
– Nasal flaring
– Pursed-lip breathing
– Retraction of the accessory muscles (intercostal
or subcostal muscles, suprasternal notch, and
supraclavicular fossa during respirations)
 Auscultation, Palpation, and Percussion Techniques
• Air movement can be evaluated by listening to respirations without using a
stethoscope or by using a stethoscope to assess bilateral lung fields.
• Palpation of the chest wall helps determine the presence or absence of paradoxical
(contrary) motion of the chest wall, inspiration, expiration, and any retraction of
accessory muscles.
• Percussion technique can be used to help determine the presence of air or fluid, such
as blood in the chest cavity when diminished breath sounds or unequal chest wall
movement is present
Other Signs of Respiratory Distress
• resistance or decreased compliance when
assisting or delivering respirations with a bag-
mask device (seen in asthma, COPD, and
tension pneumothorax) and the presence of
pulsus paradoxus.
 History
• Obtaining a history to determine the progression and duration of the
dyspneic event also helps guide the direction of patient care.
• For example, the paramedic should ask
– whether the event was sudden in onset or occurred over time.
– If it occurred over time, the length of that period should be determined.
– whether any known causes or triggers initiated the difficulty breathing and
whether the respiratory distress is continuous or recurring.
Other questions that should be asked in obtaining a patient’s history include the
following:
- What makes it better?
- What makes it worse?
- Do any other symptoms occur at the same time (eg, cough, chest
pain, fever)?
- Has any treatment with drugs been attempted?
- Has the patient taken all medications and treatments as prescribed?

It also is crucial to determine whether the patient has been previously evaluated or
hospitalized for this condition and whether the person has ever been intubated
because of respiratory problems.
 Presenting complaint
• Have you got any difficulty in breathing (DIB)?
• If the patient has a chronic respiratory condition (COPD etc.) ask them if the DIB is
normal for them.
• Are there any associated signs or symptoms?
• Are these new or old?
 History of presenting complaint
• When did the DIB start?
• What were you doing when it started?
• Have you experienced previous episodes of this before? If so, when?
• Do you have a cough?

• The paramedic/clinician should consider that a cough can be a relatively non-

specific symptom, which can occur due to irritation of the air passages from the
pharynx to the lungs

The character of the cough may however give these clues:

• Loud brassy cough – suggests pressure on trachea e.g. tumour
• Hollow ‘bovine’ cough – suggests recurrent laryngeal nerve palsy
• Barking (croup) cough – suggests acute epiglottitis, croup
• Chronic cough – suggests pertussis, TB, foreign body, asthma (e.g. nocturnal)
• Dry, chronic cough – suggests either acid irritation of the lungs, oesophageal reflux, or due to
the side effects of ACE inhibitors.
 Past medical history
• Do you have a history of a chronic respiratory illness? If so what is the condition?
• Do you suffer with asthma, emphysema or bronchitis?
• Have you ever been hospitalised with the condition/s?
• Have you spent time in intensive care with this condition/s?
• Have you ever had a pulmonary embolism?
• Have you ever had any surgery? If so, what for?
• Do you have any other medical conditions?

 Drug/medication history
• Do you take any prescribed medications?
• Do you have a history of allergies?
• If you have an allergy can you describe the symptoms you presented with?
• Have you purchased any over the counter medications?
• Have you taken any analgesics?
• If so, what time did you take the medicines?
• Are you undergoing any courses of complementary therapy?
• Do you take any recreational drugs? If so, what did you take and when?

The paramedic/clinician should note the type and dosage of each drug, the time
of day the drug is administered and whether the patient is compliant with their
medication. In addition the paramedic/clinician should take time to check if the
drug is in date.
 Subjective Data - Health History Questions
• Cough (duration, productive of sputum)
• Shortness of Breath (SOB) (with level of activity)
• Dyspnea on Exertion (DOE)
• Chest pain with breathing
• History of respiratory infections/disease (bronchitis,
emphysema, asthma, pneumonia, tuberculosis)
• Smoking history (age started, number of packs per
day, number of years smoked)
• Environmental exposure to pollution (e.g.,
occupational hazard, exposure to smoke, heavy
traffic, factory sites etc.)
• Self-care behaviors (e.g., influenza vaccine, last
tuberculosis skin test)
 Assessment of Airway
✓ Is the airway patent? Is the patient able to maintain their
own airway?
✓ Correct any airway deficits immediately by stepwise
airway management.
✓ Are there any abnormal sounds? If so, the airway may be
obstructed.
✓ Gurgling: fluid in the airway and there is need for
suction
✓ Snoring: soft tissue problem due to the tongue occluding
the airway.
✓ Stridor: upper airway problem (partial obstruction of the
larynx or trachea).
✓ Wheezing: lower airway problem (below the vocal
cords).
 BREATHING
✓ Look, listen and feel for breath sounds for no more than 10 seconds to see if the
patient is breathing.
✓ Feel for and ascertain if the trachea is central (tracheal deviation is a late sign of a
tension pneumothorax).
✓ When appropriate expose the patient’s chest and look for chest rise and fall, ascertain
the use of accessory muscles and any chest trauma (sucking chest wounds, or flail
segments, if so manage appropriately).
✓ Auscultate the chest for breath sounds over the apex, axilla and bases of both lungs
(ascertain if there are any abnormal sounds).
✓ Feel the patient’s chest for equal expansion, crepitus and tenderness.
✓ If possible measure the patient’s oxygen saturation (SpO2).

A patient with a respiratory rate of <10 or >29 breaths per minute may potentially
require ventilatory support.
Inspection of the Thorax
 Inspection of the Thorax
Inspect the shape and configuration of the thorax.
 The clavicles should be at the same height.
 The sternum should be midline.
 The ribs are sloping downward with symmetric interspaces.
 The costal angle should be less than 90 degrees.
 Development of abdominal muscles is as expected for the client’s age, weight, and
athletic condition.
Note the client’s facial expression.
 The facial expressions should be relaxed and benign, indicating an unconscious effort
of breathing.
Observe skin color and condition.
 Skin color varies among individuals, pink undertones indicate normal oxygenation.
Skin color of the thorax should be consistent with that of the rest of the body.
 Note any lesions on the skin.

 Notes:
 Pigments and levels of oxygenation influence skin color. Pallor, cyanosis, or redness
requires further evaluation.
 Misalignment of clavicles may be caused by deviations in the vertebral column such as
scoliosis.
 Asymmetry may indicate postural problems or underlying respiratory dysfunction.
 Increase in the costal angle ”barrel chest” in an adult may indicate chronic obstructive
pulmonary disease (COPD).
 The thorax of children is rounder than that of adults.
 Palpation of the thorax
- Palpate the sternum, ribs, and intercostal spaces.
- Lightly palpate the anterior thorax.
- Palpate for respiratory expansion.
- The movement of the chest beneath your hands should feel smooth
and even.
- Unilateral decrease or delay in expansion may indicate
fibrotic or obstructive lung disease or may result from
splinting associated with pleural pain.
- Palpate for tactile (/vocal) fremitus.
- - : Absent or decreased fremitus in other areas may
result from underlying diseases including emphysema,
pleural effusion, or fibrosis.
 Percussion of the Thorax
• Percussion of the anterior thorax will
yield dull sounds over solidified or
fluid-filled areas, as may exist in
pleural effusion, consolidation, or
tumor.
• Percussion over bone or organs will
yield flat or dull sounds.
• Percussion over the heart will produce
dullness to the left of the sternum
from the third to fifth intercostal
spaces.
• Percussion sounds in the lower left
thorax change from resonance to
tympany over the gastric air bubble.
• Percussion sounds in the right lower
thorax change from resonance to
dullness at the upper liver border.
Auscultation of the Thorax
Normal Breath Sounds

• Bronchial (Tracheal)
– Loud in amplitude (intensity) and high in pitch.
– Inspiration < Expiration
• Bronchovesicular
– Moderate in amplitude and moderate in pitch.
– Inspiration = Expiration
• Vesicular
– Soft in amplitude and low in pitch.
– Inspiration > Expiration
• Vesicular breath sounds are soft, low-pitched sounds that doctors
can hear throughout the lungs, sounds with higher intensity during
inspiration
• Bronchial breath sounds are loud, harsh breathing sounds. Doctors
usually associate them sounds with exhalation, as their expiratory
length is longer than their inspiratory length.. Bronchial sounds are
present over the large airways in the anterior chest near the second
and third intercostal spaces
• Bronchovesicular sounds are softer than bronchial sounds but have.
Bronchovesicular sounds are about equal during inspiration and
expiration; differences in pitch and intensity are often more easily
detected during expiration. Bronchovesicular breath sounds are
best heard between the first and second intercostal spaces of the
anterior chest.
 Abnormal Findings
Added Sounds /Adventitious Sounds
• Added or adventitious sounds are superimposed on normal
breath sounds and often indicative of underlying airway
problems or diseases of the cardiovascular or respiratory
systems.

• Adventitious sounds are classified as (1) discontinuous or (2)

continuous.
• Discontinuous sounds are crackles, which are intermittent,
nonmusical, and brief. These sounds are commonly referred to as
rales. Crackles”air passess” indicate to presence of fluid or mucus
in airway
– Fine rales are soft, high pitched, and very brief.
– Coarse rales/crackles are louder, lower in pitch, and longer.

• Continuous sounds are musical and longer than rales but do not
necessarily persist through the entire respiratory cycle. The two
types are wheezes/sibilant wheezes and rhonchi (sonorous wheezes).
– Wheezes (sibilant) are high pitched with a shrill quality.
– Rhonchi are low pitched with a snoring quality.
 Changes in the Respiratory Pattern

• Abnormal respiratory patterns are commonly seen in ill or injured patients.

• Recognizing these patterns may help paramedics determine the proper
patient care.
 Inadequate Respiration
• Inadequate respiration can occur when the body cannot
compensate for increased oxygen demand or cannot
maintain a normal range of oxygen–carbon dioxide
balance.
• Numerous factors can cause inadequate ventilation and
respiration, including infection, trauma, brainstem injury,
and a noxious or hypoxic atmosphere.
• A patient with respiratory compromise may have a
number of symptoms and various respiratory rates and
breathing patterns.
• Some medical experts distinguish between inadequate
ventilation (usually defined by the PCO2 ) and inadequate
oxygenation but normal ventilation, as seen in pulmonary
embolus and often pneumonia.