Systematic Respiratory Assessment
Respiratory emergencies are the second most common reason for EMS activation. A systematic respiratory assessment allows you to quickly determine the severity of the patient's condition, identify the likely cause, and initiate appropriate treatment. The assessment begins before you touch the patient: observe their position (tripod position suggests severe distress), work of breathing (use of accessory muscles), and ability to speak (full sentences versus one-word answers indicates severity).
The key clinical distinction is between respiratory distress and respiratory failure. Respiratory distress means the patient is working harder than normal to breathe but is still maintaining adequate oxygenation and ventilation. Respiratory failure means the patient can no longer maintain adequate gas exchange despite maximal effort. Signs of respiratory failure include altered mental status, cyanosis, inadequate respiratory effort (paradoxically, the patient may appear to stop struggling as they tire), bradycardia, and agonal breathing. Respiratory failure requires immediate intervention with positive pressure ventilation.
Lung Sound Interpretation
Auscultation of lung sounds provides critical diagnostic information. Listen bilaterally at the apices, mid-lung fields, and bases, comparing side to side:
- Wheezing: Musical, high-pitched sounds heard primarily during exhalation. Caused by narrowing of the lower airways from bronchospasm (asthma, COPD), inflammation, or secretions. Diffuse bilateral wheezing suggests bronchospasm; unilateral wheezing may suggest foreign body aspiration or localized pathology.
- Crackles (Rales): Popping or crackling sounds heard during inspiration. Fine crackles sound like hair rubbed between your fingers near your ear and suggest fluid in the alveoli (pulmonary edema, pneumonia). Coarse crackles are louder and suggest fluid in the larger airways.
- Rhonchi: Low-pitched, gurgling sounds caused by mucus or fluid in the large airways. Often cleared by coughing. Common in bronchitis, COPD, and aspiration.
- Stridor: High-pitched sound heard during inspiration (or both inspiration and expiration), indicating upper airway obstruction. Causes include croup, epiglottitis, foreign body, angioedema, and post-extubation swelling. Stridor is always a concerning finding requiring immediate assessment.
- Diminished or absent breath sounds: Decreased air movement on one side suggests pneumothorax, pleural effusion, or complete airway obstruction. Bilaterally diminished breath sounds may indicate severe bronchospasm, obesity, or shallow breathing.
Breathing Patterns
Abnormal breathing patterns provide clues about the underlying condition. Kussmaul respirations (deep, rapid breathing) suggest metabolic acidosis, most commonly diabetic ketoacidosis. Cheyne-Stokes respirations (alternating periods of deep breathing and apnea) suggest brainstem dysfunction or severe heart failure. Agonal respirations (irregular, gasping breaths) indicate impending respiratory arrest and are not effective ventilations; treat as a respiratory arrest.
Clinical Decision-Making
Combine your respiratory assessment findings to guide treatment. A patient with wheezing, prolonged expiratory phase, and a history of asthma needs bronchodilator therapy (albuterol via nebulizer or MDI). A patient with bilateral crackles, JVD, and pedal edema has pulmonary edema from heart failure and needs CPAP (if available) and nitroglycerin. A patient with unilateral absent breath sounds, tracheal deviation, and hypotension has a tension pneumothorax requiring needle decompression. Each pattern points toward a specific intervention; learning to recognize these patterns transforms your assessment from data collection into clinical decision-making.