SMART
Manual 2015
Part 3
Airway and
Breathing Chapter 3
Breathing
Part 3: The patient with Airway and Breathing difficulties
Introduction Deterioration of respiratory function is one of the major
causes of critical illness and admission to critical care units. It
is essential to recognise the early signs of airway and
breathing difficulties and know how to manage patients
who experience these problems. This chapter will discuss
common causes of airway compromise and acute
breathlessness and consider management of such patients
using the ABCDE approach. First Impressions: The initial view of the patient as you approach them and
introduce yourself can be enlightening. It gives an overview of
the patient's general condition. If the patient is sat upright with
eyes open, and is able to respond appropriately without pausing
to breathe in mid sentence you know that - the airway is patent,
they are not in severe respiratory distress, and they are
perfusing their brain. At this point, just a few seconds into assessment, start
oxygen as this is essential, and then call for immediate
assistance if you have any concerns about the patient.
A full assessment using the ABCDE method must now be
undertaken as this is more in-depth and requires the use of
sight, sound and touch – known universally as the look, listen,
feel and treat approach. Initially these assessment skills are
under-developed but as you become more practised they will
become stronger, enabling the experienced practitioner to
undertake a detailed ABCDE assessment very quickly.
Airway
The airway is a hollow passage carrying airflow to the areas
which can exchange Oxygen and Carbon Dioxide, the lungs. It is
approximately 200mls of redundant space, which means that
other than carrying air it has no absorbent properties. This means
that it has to remain clear at all times, and any degree of
obstruction is dangerous. This can be an incomplete, partial
obstruction to a total, complete loss of patency – such
obstructions can be corrected with appropriate care, but can be
made worse through inappropriate care or even lack of attention. The common perception is that the most manageable part is the
upper airway which lies between the mouth/nose and the
pharynx. Whilst this is true to some extent, it is important to
remember that the airway stretches down through the larynx,
trachea and bronchus to the alveoli and this can be equally
managed. Factors which cause airway obstruction: • Reduced consciousness • Foreign objects eg, pen tops, food debris, vomit, blood,
sputum, teeth
• Bronchospasm • Infection causing swelling • Allergic reaction (anaphylaxis) Assessing the Airway
Look
Look inside the mouth to see if anything is causing an
obstruction. If there is mouth soiling, such as vomit assume that
the patient has aspirated. It would be dangerous to perform a
blind Mouth Sweep in case the obstruction is worsened, but if it
is safe to do so you may remove any solid foreign body visible in
the mouth. Look for condensation in the oxygen mask. This will appear as
though the mask is steaming up and is a good sign of air flow.
Listen
Assess presence of speech – if the patient can speak clearly the
airway is patent. Other noises can be indicative of problems with
the airway:
Snoring the most recognisable noise – it happens in everyday
life when people are sleeping as it is a sign of deep
unconsciousness. The noise occurs when air intermittently
passes over and behind the collapsed tongue, which under
normal circumstances is held in place by muscles attached to
the floor of the mouth. The Brain regulates and controls these
muscles but when the person becomes unconsciousness, for
whatever reason, the tongue falls back against the pharynx
causing life threatening obstruction.
Stridor is an inspiratory noise which comes from air flowing
through the swollen, narrowed larynx. It can be caused by viral or
bacterial infection, anaphylaxis or thick Sputum, and so the
problem needs to be resolved whilst the patient is supported
through with oxygen.
Gurgling the noise made when air is flowing back and forth over fluid.
This is usually Sputum, but it can also be fluid such as vomit, which
can submerge the lungs or irritate them causing aspiration
pneumonia. The noise can occur along the length of the airway – in
the upper airway they sound like gurgles, and can be removed with a
Yankeur Sucker, but they can also be heard on auscultation in the
lower respiratory tract, using a stethoscope. Patients who retain
secretions can become tired and at some point will deteriorate rapidly.

The conscious
patient needs to be re-positioned in a semi-upright
position, given plenty of humidification and encouraged to take some
deep breathes as the stimulus for coughing. You need to promote
effective coughing but this may be difficult as it relies upon muscle
strength and compliance. If the patient has a weak cough, or is
unconscious the doctor must be alerted urgently. Finally, there is the presence of silence. This is a sign of
complete obstruction and goes hand in hand with Seesaw
breathing, and is an imminent sign of Respiratory Arrest. This is a
medical emergency.
Feel The only recommendation is to feel for airflow by placing your
cheek or hand gently over the mouth. This works on the same
principle as an oxygen mask which has condensation from
breathe – you can feel the airflow and occasionally the moisture
from each breathe. Treat Treat any problems you find with Airway as you go along. Open
the Airway using head tilt chin lift. If there are secretions in the
oropharynx use the yankeur sucker to remove them, if the patient
cannot maintain their own airway without you applying head tilt
chin lift then insert an oro pharyngeal or nasopharyngeal airway.
Always apply 100% oxygen at A (Airway) Breathing
It is important that you have successfully managed the airway
before moving onto focus upon breathing, otherwise whatever you
do will be futile regardless of the correct treatment. At a very basic level breathing describes the essential exchange
of oxygen and carbon dioxide. This is described as External
Respiration as it is the point when the atmosphere meets the
circulation, at the interface known as the Alveolar-Capillary
membrane. The effectiveness relies upon two working systems,
the expansion of the alveoli and the flow of the blood around the
lungs, the pulmonary vasculature. In practice, this is known as
the V:Q ratio (V for Ventilation and Q for Perfusion) and when
assessing a patient it is interesting to consider which side of this
equation is being adversely affected as this will help to make
sense of the deterioration. Please click the link below to watch a short talk from the 2014
Trauma Conference about airway management and the use of
nasopharyngeal airways.
Link to trauma conference airway film
Causes of breathlessness
Patients can sometimes be breathless without having a problem
with their lungs. Some disease states cause acid to build up in the
blood for example lactic acid in sepsis. The body will try and
counteract this acid build up by breathing faster to blow off more
carbon dioxide which is also an acid. All tissues require oxygen for survival and Oxygen delivery
depends on: • Adequate ventilation (getting sufficient amounts of air into and out
of the lungs) • Gaseous exchange (Oxygen and carbon dioxide need to be able
to pass from the alveoli to the blood and visa versa) • Effective circulatory distribution of the oxygenated blood Initial treatment of breathing Assess Airway
Give High Flow Oxygen
If breathing is very shallow or respiratory rate is very low (<8)
you may need to support the patients breathing by giving
some additional breaths with the bag valve mask connected
to high flow oxygen
If giving nebulisers ensure that these are given with oxygen
and not air
Do not remove the oxygen at any time (this includes when
taking an arterial blood gas sample [ABG] )
Assessment of the breathless patient
A lot of information can be obtained about a patients breathing
from taking a general look at them as you approach them or from
the end of their bed. From this initial general look you can gain
valuable information such as the patients colour, whether they
look anxious or relaxed, and how hard they have to work to
breathe. When you first talk to the patient you will get an
impression of how easy they find it to talk. Inability to answer you
in full sentences is a sign of severe respiratory distress. The look,
listen and feel approach can then be effectively used to evaluate
the effectiveness of breathing in more detail. In all patients who are acutely short of breath, or who have
respiratory rates that are above 30 or below 8, call for medical
help right away. The priority is to correct life threatening
physiology such as hypoxaemia (low oxygen saturations). Look
Check the patient's general COLOUR Are there any signs of
cyanosis (a blue/purple tinge around the lips?) which indicates
hypoxia? Central cyanosis is a bluish or purple tinged appearance to the
lips. This occurs when there is more than 5gm/dl of deoxygenated
haemoglobin in aortic blood and is usually detectable when the
arterial oxygen saturation is < 85%. It is important to remember if
the patient is anaemic cyanosis may not be evident during
hypoxia. Common causes of central cyanosis are acute e.g.
Pneumonia, asthma, pulmonary oedema, and chronic e.g. COPD. N.B. Cyanosis is a late sign and absence of cyanosis does not
mean that the patient is not hypoxic or in respiratory distress Look For evidence of 'see saw' breathing pattern also known as
paradoxical breathing. In normal breathing the abdomen and the
chest move in the same direction during inspiration (outwards)
and expiration (inwards). If the airway is obstructed the
abdomen and chest move in different directions so on inspiration
the abdomen moves inward as the chest moves outward and for
expiration the reverse pattern is seen
Look
Is the patient ALERT and ORIENTATED indicating that the brain
is receiving sufficient oxygen, or are they drowsy or
unresponsive? Look
Is the patient FRIGHTENED and CONFUSED. Hypoxia can
cause confusion. Patients in severe respiratory distress usually
look very frightened and will often become restless and try to
remove their oxygen mask saying that they feel the mask is
suffocating them and they need air. Look
What is the patients POSTURE like? are they leaning forward or
are their arms outstretched gripping the cot sides tightly? Both of
which can be signs of respiratory distress. LOOK
Are they using their ACCESSORY MUSCLES in the neck and
shoulders to breathe? Or are they using their ABDOMINAL
MUSCLES? The most sensitive indicator of deterioration in a patient is a rise
in RESPIRATORY RATE. Also observe DEPTH AND RHYTHM OF BREATHING.
The number of times the chest rises in 60 seconds is the
respiratory rate measured as breaths per minute. The normal rate
for an adult at rest is 12-18 breaths per minute. The term
tachypnoea describes an abnormal fast rate of breathing, usually
more than 20 breaths per minute, and is usually the first sign of
respiratory distress. Bradypnoea describes an abnormally slow
rate of breathing, usually less than 12 breaths per minute. If a
patient's respiratory rate is very slow < 8 they may need to have
their breathing supported via a bag valve mask with a reservoir
bag connected to high flow oxygen. A patients respiratory rate may slow down appropriately in
response to treatment but if the underlying problem has not been
corrected a slowing respiratory rate may be an indication that a
patient is becoming exhausted and moving towards a respiratory
arrest.
LISTEN
When listening to a patients chest with a stethoscope normal
breathing sounds should be bilateral and audible in all lung zones. Noisy breathing is a sign of respiratory distress. Stridor is a highly pitched sound normally occurring on
inspiration due to a laryngeal or tracheal obstruction. Wheeze is characterised by a noisy musical sound caused by the
turbulent flow of air through the narrowed bronchi and bronchioles
(Jevon and Ewens 2001). A `wheeze` is more pronounced on
expiration and often associated with asthma and COPD. Rattly chest is caused by the presence of fluid {pulmonary
oedema or sputum} in the upper airways. Can the patient speak in full sentences? if not the patient's
speech needs to be further analysed. This time it isn't just the
presence of speech but how fluent the sentences are. Normally,
speech is continuous with subtle breathes at appropriate times.
Consider your own speech and you will realise that normal
breathing aids this practiced activity. Is the patient orientated or confused? FEEL Check if both sides of the chest are expanding Are there any
signs of surgical emphysema? Is the trachea central? Deviation
may suggest pneumothorax Does the patients skin feel clammy? The patients breathing pattern can be confirmed by placing hands
on the chest, one on each side and checking for symmetry and
regularity. Respiratory failure is when the respiratory system is failing in
its primary function of getting sufficient oxygen into the blood
and removing carbon dioxide. Respiratory failure is diagnosed
from arterial blood gases which show the Ph of the blood and
the levels of oxygen and carbon dioxide. There are two types
of respiratory failure:
Type 1 respiratory failure: describes hypoxia with a normal or
low CO2 and is primarily due to pathology affecting
oxygenation alone for example pneumonia or PE Type 2 respiratory failure: describes hypoxia with
ventilatory failure which causes a high carbon dioxide level
(hypercapnia). As carbon dioxide is an acid, high CO2 levels
make the blood more acidic. The use of pulse oximetry
Pulse oximetry is a non invasive procedure which measures the
amount of oxygen saturated haemoglobin circulating in
arterial blood. Normal values of oxygen saturation vary between 95-98%, and values below are normally
a cause for concern, however in patients with COPD
saturations may be as low as 85% as they will adapt over a
long period of time to survive with lower oxygen saturations. Pulse oximetry is normally monitored on a patients finger {ensuring
nail varnish is removed} but there can be special probes to monitor
these on the patients ears. Patients who are acutely breathless
should have continuous monitoring. It is important to ensure that
the finger probe position is changed regularly if it is on for
prolonged periods as pressure sores can develop. N.B. Pulse oximetry is a very useful monitoring tool but it
does not measure carbon dioxide, this has to be monitored
through the analysis of an arterial blood gas. When ever blood gases are taken oxygen therapy should not be
removed. The amount of oxygen the patient is on when a blood
gas is taken should always be recorded in the patient's notes
(Woodrow 1999). Treatment: Oxygen therapy
High flow oxygen should be administered to all critically ill
patients in order to maintain optimal tissue oxygenation and
prevent organ failure. High flow oxygen and the patient with COPD Nurses and doctors are often reluctant to give COPD patients high
concentrations of oxygen in case they are carbon dioxide
retainers. Carbon dioxide is our normal stimulus to breathe. If CO2
rises we breathe more rapidly. However in a small minority of
COPD patients who have high CO2 levels all the time this no
longer works and the body then uses a low oxygen level as the
stimulus to breathe. If these patients have high concentrations of
oxygen they may loose their stimulus to breathe and their
respiratory rate will drop and their carbon dioxide levels will rise. However in the acute situation where a patient is critically ill, it is
regarded as safe practice to give high flow oxygen to all patients
initially whilst you summon medical help in order to protect the
patient from becoming hypoxic. Hypoxia is more dangerous than
high carbon dioxide levels and will cause patients to have a
cardiac arrest if severe or prolonged. The target saturation level
for those with COPD is 88 - 92%.
Do not withhold high flow oxygen from patients with COPD
who are critically ill as hypoxia can kill. If you know the patient
has COPD then get senior help and when the doctor arrives a
blood gas can be obtained quickly and oxygen concentration
can be titrated downwards with a different type of mask such
as a venturi to maintain the patients oxygen saturations at 88
– 92% a safer level for those with COPD. • Reservoir bag Mask (these are referred to in practice as
Non-rebreathe masks or Trauma masks): These masks have
an additional oxygen reservoir bag attached to the mask. Prior to
application to the patient , the reservoir bag should be inflated by
occluding the one way valve and setting the oxygen flow rate to
15 litres / minute. During inspiration, oxygen is drawn from the
mask and the reservoir allowing oxygen concentrations of up to
85% to be achieved
Please tap the arrow to play a short film
• Simple Face Masks: These are frequently used in
clinical areas and can achieve a total oxygen delivery of
up to 60% with a maximum flow rate of 10 litres / min. The
minimum flow rate used with this mask should be 5 litres /
minute in order to eliminate the build up of exhaled
carbon dioxide. For any given flow rate, the inspired
oxygen concentration achieved will vary, as it depends
upon the rate and depth of the patients breaths and the
resulting inspiratory flow rate. The inspiratory flow rate is
the amount of gas that we breathe in every minute. Each
breathe is normally about 500 mls so if we breathe at a
rate of 20 bpm the inspiratory flow rate would be 10 L /
min. When patients are unwell with fast respiratory rates
the inspiratory flow rate may be as high as 25 - 30 L/min.
If the gas delivered via the oxygen mask doesn't match
this flow rate the patient will entrain room air to
compensate, which results in the oxygen delivered being
diluted.
• Nasal Cannula: These are capable of delivering an
inspired oxygen concentration of between 24-40% depending on
the flow rate of the oxygen (1-4 L). For any given flow rate, the
inspired oxygen concentration achieved will vary, as it depends
upon the rate and depth of the patients breaths. The maximum
flow rate is 4 litres / minute because higher rates can cause nasal
mucosal drying and epistaxis • Venturi Masks: Venturi systems allow specific levels of air entry
so that air is mixed with the oxygen administered, to deliver
precisely controlled percentages of high flow oxygen at low to mid
concentration 24-60% and the valves are colour coded according
to the % of oxygen delivered. These masks are useful in
patients where specific oxygen concentration is required for
example in COPD patients.
Prevention of breathing problems Breathing problems can sometimes be prevented. Good pain
relief after abdominal or thoracic surgery helps to ensure that
patients can deep breathe and cough effectively which reduces
the risks of patients developing hospital acquired pneumonia post
operatively. Sitting patients' upright and ensuring they are pain
free maximises respiratory function. If patients are stable enough
sitting out of bed in a chair assists basal expansion. Relieving
abdominal distension caused by a paralytic ileus or from ascites
will allow the patient to breathe more deeply. Turning immobile patients regularly not only prevents pressure
sores but plays a valuable role in helping to expand different parts
of the lungs and mobilise secretions. If patients are receiving high
flows of oxygen for prolonged periods humidification will help
prevent drying and retention of secretions. Refer any patients
with breathing difficulties to the physiotherapist. Patients who are
not able to get out of bed should be encouraged to perform deep
breathing exercises hourly to help prevent retention of secretions,
and basal collapse. As with all acutely ill patients: • Airway is always assessed first before breathing.
• Apply oxygen via reservoir mask at 15 L/min and call for
medical help right away • Monitoring should include respiratory rate and continuous
pulse oximetry
• Reassess ABCDE after any change or deterioration in condition Remember COPD patients need to be observed closely when
on high flow oxygen and need an urgent medical review and
arterial blood gas References
ALERT (2000) Acute, Life threatening, Events, Recognition and
Treatment Course Manual. University of Portsmouth Bennett, C (2003) Nursing the breathless patient Nursing
Standard 17: 17 45-41 BTS (2007) Guidelines for emergency oxygen use in adult
patients. BTS Publishing UK Goldhill D et al (1999) Physiological values and procedures in
the 24 hours before ICU admissions from the ward Anaesthesia
54,6 529-534 Jevon, P Ewens B (2001) Assessment of a breathless patient
Nursing Standard 15,16 48-53 Jevon, P Ewens, B (2000) Practical procedures for nurses,
pulse oximetry Nursing Times 96, 26 43-44