Difficulty in Breathing

Basic Emergency Care Course

 Objectives

• Recognize the signs of difficulty in breathing (DIB)

• List the high-risk causes of DIB
• Perform critical skills for high-risk causes of difficulty in breathing
 Essential Skills
• Basic airway manoeuvres
• Basic airway device insertion
• Management of choking
• Oxygen administration
• Bag-valve-mask ventilation
• Needle decompression for tension pneumothorax
• Three-sided dressing for sucking chest wound
 !
The ABCDE Approach
REMEMBER …………
Always start with the ABCDE Approach AND treat life-threatening
conditions

Then take a SAMPLE history

Then do a Secondary Exam

Key Elements in the ABCDE Approach
Airway:
• Swelling (allergic reaction)
• Choking (foreign body obstruction)
• Listen for stridor (serious airway narrowing)

Breathing:
• Signs/ symptoms of tension pneumothorax
• Absent breath sounds on one side with hypotension
• Distended neck veins
• Tracheal shifting
• Listen: wheezing may indicate asthma or allergic reaction
Key Elements in the ABCDE Approach
Circulation:
• Check capillary refill, heart rate, rate of breathing and blood pressure for signs
of poor perfusion
• Shock, heart attack, heart failure or severe infection can present with poor
perfusion and difficulty in breathing
• Check for leg swelling or lung crackles which may be signs of heart failure

Disability
• Check level of consciousness with AVPU
• Patients with decreased level of consciousness may not be able to
protect their airways
• Drugs/infection/injury can affect the part of the brain that controls breathing
• Check for paralyzing conditions that can affect breathing muscles

Exposure
• Look at chest wall movement
• Check for penetrating trauma
The SAMPLE History
 ?
S: Signs and Symptoms
• ASK:
• When did the symptoms start?
• Was the onset sudden?
• Do they come and go?
• How long do they last?
• Have they changed over time?
• Any similar episodes?
• ect…
SUDDEN onset shortness of breath THINK:
• Obstruction of the airway
• Foreign body
• Swelling of the airway
• Trauma to the airway, lung, heart or chest wall
• Toxic inhalation
• Sudden heart problems
• Heart attack
• Abnormal rhythm
• Valve problems
• Rapid deep breathing
• Poisoning
• High acid levels (diabetic ketoacidosis)
• Anxiety
SLOWER onset shortness of breath THINK:
• Infections
• Fluid in the lungs
• TB and heart failure
• Fluid around the heart
• TB or kidney disease
• Lung cancer
• Diseases affecting muscles of chest wall
• Asthma or COPD
S: Signs and Symptoms

?
• ASK:
• Was there anything that triggered the difficulty in breathing?
• What makes it better or worse?

• THINK
• Allergies-> airway blockage from swelling
• Inhalation (fire or chemicals) -> airway swelling
• Chemicals and pesticides -> fluid in lungs or muscle weakness
• If lying flat worsens breathing this suggests fluid in the lungs
S: Signs and Symptoms

?
• ASK:
• Is there any tongue or lip swelling or voice changes?

!
• THINK
• Swelling to mouth, lips, tongue, upper throat and voice changes
suggest severe allergic reaction and inflammation in the airway
WATCH CLOSELY
S: Signs and Symptoms
• LISTEN
• Are there any abnormal breath sounds?

• THINK
• Stridor (high pitched ”squeaking” sound during inhalation
• UPPER AIRWAY swelling or blockage
• Wheezing (high pitched sound during exhalation)
• LOWER AIRWAY narrowing or spasms in the lungs
• Asthma, COPD, heart failure, allergic reactions
• Gurgling: (low pitched bubbling)
• Mucous or fluid in the airway
S: Signs and Symptoms
• ASK
• Is there any pain associated with the difficulty breathing?

• THINK
• If the patient has chest pain with difficulty in breathing:
?
• Heart attack
• Pneumothorax
• Pneumonia
• Trauma to lungs, ribs or muscles
• Pleuritic pain (worse with deep breaths)
• Infection
• Blood clot in lung (pulmonary embolism)
S: Signs and Symptoms
• CHECK
• Is there a fever?
• Is there a cough?

• THINK
• Fever suggests an infection
• Cough with fluid sounds could be pneumonia or oedema
• Cough with a wheeze suggests asthma or COPD
S: Signs and Symptoms
• CHECK
• Foot and leg swelling
• For recent pregnancy

• THINK
• Oedema to both feet and legs suggests heart failure
• Swelling and pain to one leg suggests a blood clot that could travel to
lung (pulmonary embolism)
• Pregnancy is a risk factor for both pulmonary embolism and heart
failure
A: Allergies
• ASK
• Allergies to medications or other substances?
• Recent insect bites or stings?

• THINK
?
• Severe allergic reactions can cause airway swelling and difficulty breathing
• People can have allergic reactions to almost anything
• Food
• Plants
• Medications
• Insect bites/stings
M: Medications
• ASK
• Currently taking any medications?
?
• THINK
• New medications or change in dosages can cause allergies and difficulty
breathing
• Accidental overdose of some medications can slow or stop breathing
P: Past Medical History
• ASK
• History of asthma or chronic obstructive pulmonary disorder (COPD)?
• History of heart disease or kidney disease?
• History of tuberculosis or cancer?
?
• THINK
• Asthma and COPD cause episodes of DIB
• Heart or kidney failure can cause a fluid build-up in the lungs
• Heart attacks may present with difficulty in breathing
• Pericardial effusions and pleural effusions can be caused by cancer,
tuberculosis or kidney problems
P: Past Medical History

?
• ASK
• History of diabetes?
• History of smoking?
• History of HIV?

• THINK
• Diabetics can have fast breathing from diabetic ketoacidosis
• Smoking increases the risk of asthma, COPD, lung cancer, heart attack
• HIV increases the risk of infection
L: Last Oral Intake
• ASK
• When did the patient last eat or drink?
?
• THINK
• Full stomach puts the patient at risk for vomiting and aspiration
E: Events Surrounding Illness
• ASK
• What was the person doing when the difficulty in breathing started?
?
• THINK
• DIB after eating, think choking
• DIB with exercise and chest pain, think heart attack
E: Events Surrounding Illness
• ASK
• Was the patient found in or near water?

• THINK
?
• Consider drowning (inhalation of water) if a person is found in or near water

!
• Even a small amount of inhaled water can cause serious lung damage
• Worsens over time. WATCH CLOSELY
E: Events Surrounding Illness
• ASK
• Has there been any exposure to pesticides or inhaled chemicals?
?
• THINK
• Pesticides used in farming can be absorbed through the skin and
cause fluid in the airways and lungs
• Exposure to gases from a fire can cause chemical inhalation
E: Events Surrounding Illness
• ASK
• Has there been any recent trauma?
?
• THINK
• Rib fractures
• Pneumothorax
• Haemothroax
• Heart or lung bruising
Workbook Question 1
Using the workbook section above, list 5 questions about PAST
MEDICAL HISTORY you would ask when taking a SAMPLE
history

1.
2.
3.
4.
5.
 Secondary Exam Findings
• Look, listen and feel
• Difficulty in breathing may present with:
• Changes in the respiratory rate
• Changes in the respiratory effort
• Low oxygen levels in the blood

!
*Remember you should have ALREADY completed the ABCDE Exam and
treated life-threatening conditions BEFORE doing this extensive examination
*If the secondary exam identifies an ABCDE condition, STOP AND RETURN
IMMEDIATELY TO ABCDE to manage it.
Secondary Exam Findings
• Look for signs of respiratory failure
• Accessory muscle use and increased work of breathing
• Difficulty speaking in full sentences
• Inability to lie down or lean back
• Diaphoresis and mottled skin
• Confusion, irritability, agitation
• Poor chest wall movement
• Cyanosis
Secondary Exam Findings
• Look at pupil size and reactivity
• Small pupils suggest possible medication overdose or exposure to chemicals
(usually pesticides)
• Unequal or abnormally shaped pupils suggest head injury which can cause
abnormal breathing

Source: WHO Pocket Book for Hospital Care of Children. 2nd Ed. 2013.P168
Secondary Exam Findings
• Look at the face, nose and mouth
• Cyanosis around the lips or nose suggests low oxygen levels in the
blood
• Pale lower eyelids may suggest anaemia
• Swelling of the lips, tongue and back of mouth suggest allergic reaction
• Soot around the mouth or nose, burned facial hair or facial burns
suggests smoke inhalation
• Bleeding, swelling or abnormal airway shape may be due to trauma
Secondary Exam Findings
• Look at the neck and chest
• Distended neck veins suggests heart failure, tension pneumothorax or pericardial
tamponade
• Excessive muscle use of neck and chest suggests significant respiratory difficulty
• Tracheal shift suggests tension pneumothorax or tumour
• Swelling of the neck suggests infection or trauma
• Examine the entire neck and chest carefully for signs of trauma
Secondary Exam Findings
• Look at the rate and pattern of breathing
• Longer exhalation time due to narrowing of lower airways
• Asthma
• Fast breathing
• Dehydration
• Severe infection
• Chemical imbalances in the blood
• Poisoning
• Anxiety
• Slow and shallow breathing
• Opioid overdose
• Flail chest
• Occurs with multiple rib fractures when a segment of rib cage separates from the rest of
the chest wall
Secondary Exam Findings
• Look at both legs
• Swelling to both legs (heart failure)
• Swelling to one leg with pain (blood clot)

• Look at the skin

• Bites (allergic reaction)
• Rashes (allergic reaction or systemic infection)
• Hives
• Pallor (anaemia)
• Burns that wrap around torso
• Can restrict chest wall expansion
Secondary Exam Findings
• Listen to breath sounds
• Stridor
• Partial upper airway obstruction-
• Foreign body
• Swelling
• Trauma
• Infection
• Decreased breath sounds
• Something preventing air from entering the lung
• Pneumothorax
• Haemothorax
• Fluid
• Foreign body
• Infection inside the lungs or tumour
Secondary Exam Findings
• Listen to breath sounds
• Wheezing
• Lower airway obstruction
• Asthma
• Allergic reaction
• Tumour
• Foreign object
• Crackles
• Fluid build-up in the airways of the lungs

Try to listen to breath sounds often so you can know

what is normal and what is not!
Secondary Exam Findings
• Listen to heart sounds
• Abnormal heart rhythms can cause the heart to pump blood poorly
• Poor perfusion
• Heart murmurs with difficulty breathing
• Heart valve disease or injury
• Muffled or distant heart sounds with low blood pressure, fast heart rate and
distended neck veins suggests pericardial tamponade
Secondary Exam Findings
• Feel the chest wall (ribs)
• Deformities or abnormal movements suggests rib fractures
• Crepitus suggests underlying fracture or pneumothorax
• Unequal chest expansion
• Pneumothorax, haemothorax, flail chest

• Percuss the chest wall

• Hollow sounds (hyperresonance)
• Pneumothorax
• Dull sounds
• Fluid or blood
Workbook Question 2

Using the workbook section above, List 3 signs you should

LOOK for in a patient with difficulty in breathing:
1.

2.

3.
Workbook Question 2
List 4 things you should LISTEN for in a patient with difficulty in breathing:

1.

2.

3.

List 3 things you should FEEL the chest wall for in a patient with difficulty in breathing:
1.

2.

3.
Possible Causes of
Difficulty in Breathing
 Key AIRWAY causes of DIB
• Foreign body obstruction
• Acute difficulty breathing
• Visible secretions, vomit or foreign body
• Abnormal sounds from the airway (stridor, snoring, gurglig)
• Coughing
• Drooling

• Severe allergic reaction

• Swelling of lips, tongue and mouth
• Stridor and/or wheezing
• Rash or hives
• May have tachycardia and hypotension
• Exposure to known allergen
 Key AIRWAY causes of DIB
• Airway swelling (inflammation or infection)
• Stridor
• Hoarse voice
• Drooling or difficulty swallowing (indicates severe swelling)
• Unable to lie down
• May have fever (with infection)
 Key AIRWAY causes of DIB
• Airway burns
• History of exposure to chemical or fire
• Facial burns (singed facial hair)
• Stridor
• Change in voice
 Key LUNG causes of DIB
• Pneumonia
• Fever and cough
• Gradually increasing work of breathing
• Worsening pain with breathing (pleuritic)
• Abnormal lung exam (LISTEN for crackles)
 Key LUNG causes of DIB
• Asthma/ COPD
• Wheezing
• Cough
• Accessory muscle use
• Tripod position
• May have history of smoking or allergies

Tripod position
 Key LUNG causes of DIB
• Pneumothorax
• Decreased breath sounds on one side
• Sudden onset
• Hyperresonance with percussion on affected side
• Pain worse with breathing
• May have history of trauma or evidence of rib fracture
• Hypotension, distended neck veins and decreased breath sounds on one side
indicate tension pneumothorax

An untreated pneumothorax can develop

into a tension pneumothorax!
 Key LUNG causes of DIB
• Haemothorax
• Decreased breath sounds on affected side
• Dull sounds with percussion
• May have history of trauma, cancer or tuberculosis
• May have symptoms of shock if large haemothorax
 Key LUNG causes of DIB
• Pleural effusion
• Decreased breath sounds on one or both sides
• Dull sounds with percussion
• May have history of cancer, tuberculosis, heart disease or kidney disease
• Acute or chronic difficulty breathing
 Key LUNG causes of DIB
• Acute chest syndrome (sickle cell patients)
• History of sickle cell disease
• Chest pain
• Fever
• Hypoxia
 Key CARDIAC causes of DIB
• Heart attack
• Chest pressure, tightness or crushing feeling in the chest
• Diaphoresis and mottled skin
• Nausea or vomiting
• Signs of heart failure
• History of smoking, cardiac disease, hypertension, diabetes, high cholesterol,
family history of heart problems
 Key CARDIAC causes of DIB
• Heart failure
• Difficulty in breathing with exertion
• Difficulty in breathing when lying flat
• Swelling to both legs
• Distended neck veins
• Crackles may be heard in the lungs
• May have chest pain
 Key CARDIAC causes of DIB
• Cardiac tamponade
• Signs of poor perfusion (shock)
• Tachycardia, tachyponea, hypotension, pale skin, cold extremities,
capillary refill greater than 3 seconds
• Distended neck veins
• Muffled heart sounds
• May have dizziness, confusion or altered mental status
• May have history of tuberculosis, trauma, cancer, kidney failure
 Key SYSTEMIC causes of DIB
• Anemia
• Pale skin and inner lower eyelids
• Tachycardia
• Tachypnoea
• History of haemorrhage, malnourishment, cancer, pregnancy, infections
(tuberculosis or malaria), renal failure
• Opioid overdose
• Clinical or recreational opioid use
• Altered mental status
• Change in pupil size
• Slow, shallow breathing
 Key SYSTEMIC causes of DIB
• Diabetic Ketoacidosis (DKA)
• History of diabetes
• Rapid or deep and slow breathing (Kussmaul breathing)
• Frequent urination
• Sweet smell to breath
• High glucose in blood or urine
• Dehydrated
 Workbook Question 3
Using the workbook section above, list the possible cause of Difficulty In Breathing next to the
history & physical findings below:
History and Physical Findings: Likely Cause:
A 20 yr male presents with difficulty breathing, wheeze and:

Swelling of lips, tongue and mouth

Rach or hives (patches of pale or red, itchy, warm, swollen skin)
Tachycardia and hypotension
History of allergies
Exposure to known allergen
A 50 yr woman presents with difficulty breathing, signs of poor persusion
(tachycardia, tachypnoea, hypotesion, pale skin, cold extremities, capillary refill
greater than 3 seconds) and:

Distended neck veins

Muffled heart sounds
History of tuberculosis
Management of
Difficulty in Breathing

REMEMBER treat ABCDE problems and life-threatening conditions first

Management
• If suspected airway inflammation or burns:
• Keep patient calm
• Give OXYGEN if it does not upset the patient
• If patient is alert without other injuries, seated upright may make the patient
more comfortable
• Consider early advanced airway management
• Delays in intubation-> worsening swelling-> increased difficulty breathing
-> difficult intubation
• Plan for rapid HANDOVER/TRANSFER
Management
• If suspected choking:
• Use age-appropriate chest thrusts/abdominal thrusts/back blows
Management
• If suspected choking in infants:
• In infants, alternate between 5 back blows and 5 chest thrusts
Management
• If suspected allergic reaction:
• Remove allergen
• For severe allergic reaction with difficulty breathing
• Give intramuscular ADRENALINE without delay
• Give OXYGEN
• If suspected asthma/COPD
• Give SALBUTAMOL
• Give OXYGEN if indicated
• If suspected DIB from fever
• Give ANTIBIOTICS as soon as possible
• If signs of poor perfusion, give IV FLUIDS
Management
• If suspected heart attack:
• Give ASPIRIN
• With symptoms of shock or difficulty breathing give OXYGEN
• If patient has NITROGLYCERIN, assist them in taking it

• If suspected chronic, severe anaemia:

• Give IV FLUIDS slowly
• Listen frequently for crackles in the lungs (fluid overload)
• Prepare for handover/transfer for possible BLOOD TRANSFUSION

• If suspected diabetic ketoacidosis (DKA):

• Give IV FLUIDS
• Prepare for urgent transfer
Management
• If suspected opioid overdose
• Support breathing with a BAG-VALVE-MASK as needed
• Give NALOXONE

• If suspected large pleural effusion or haemothorax:

• Give OXYGEN
• Arrange for urgent HANDOVER/TRANSFER
• Patient requires CHEST TUBE or drain
Management
• If suspected trauma:
• Give OXYGEN
• If tension pneumothorax or cardiac tamponade give IV FLUIDS
• If tension pneumothorax is suspected perform NEEDLE DECOMPRESSION as
soon as possible
• Prepare for rapid transfer for chest tube insertion
• Treat sucking chest wounds with a 3-sided occlusive dressing
• Prepare for rapid transfer for chest tube insertion
Management
• If suspected acute chest syndrome
• Give OXYGEN
• Give IV FLUIDS
• May need HANDOVER/TRANSFER
Workbook Question 4
Using the workbook section above, list what you would DO to
manage a person who presents with:
DIB, coughing and you suspect choking
1.
2.

DIB, high fever, cough and you suspect serious infection

1.
2.
Workbook Question 4
Using the workbook section above, list what you would DO to
manage a person who presents with:
DIB, hoarse voice and stridor on breathing in. You suspect airway inflammation

1.
2.
3.
Special Paediatric Considerations: Danger Signs

• Signs of airway obstruction (unable to swallow, drooling, stridor)

• Increased breathing effort
• Cyanosis
• Altered mental status
• Poor feeding
• Vomiting everything
• Seizures/Convulsions
• Low body temperature
Special Paediatric Considerations:

• Wheezing in children can be a viral infection or a foreign object

• Stridor can be caused by airway swelling or a foreign object

• Rapid breathing may be the only sign of pneumonia

• Rapid breathing can indicate DKA as the first sign of diabetes in

children
Workbook Question 5
Using the workbook section above, list the paediatric
danger signs:

1.
2.
3.
4.
5.
6.
7.
8.
Disposition of the Patient
• Ongoing Monitoring
• Inhaled medications such as salbutamol only last approximately 3 hours
• A severe allergic reaction can return when adrenaline wears off
• Naloxone only lasts about 1 hour and may require repeat doses
• Most opioid medications last longer than this
• Following submersion injuries, a person may develop breathing problems
later on

Remember these patients need to be monitored closely!

Transport Considerations
• Never leave a patient who might need definitive airway placement
unmonitored during handover/transfer

• Make transfer arrangements as early as possible for any patient who

may require assisted ventilation
 !
Remember
• Perform ABCDEs first
• Treat life-threatening conditions
• Take a SAMPLE history
• Do an extended physical examination
• Think about causes
• Think about considerations in children
• Think about disposition and transport
Questions

?
Quick Cards