B

Breathing

RECOGNITION

Specific management will depend on the cause of the respiratory failure (see further management section). Immediately life threatening respiratory conditions such as a severe asthma, tension pneumothorax or haemothorax should be treated without delay.

Ensure airway patency

Oxygen

Reservoir mask

Initial management of an acutely unwell patient involves giving the patient O₂ at 15L/min via a reservoir mask.

Following review by an expert it may be decided that supplemental oxygen via a reservoir mask is not required. This is highlighted in the BTS guideline “Oxygen Therapy Use in Adults in Healthcare and Emergency Settings” and in the Oxygen therapy section on the next page”

Sit the patient up and attach monitoring (Pulse oximeter (O₂ saturations monitor), Electrocardiogram (ECG), Blood pressure (BP) cuff).

The look, listen, feel approach can be used to assess breathing.

Video: Look, Listen, Feel breathing assessment.

LOOK

Respiratory rate
Depth and symmetry
Cyanosis (central)
Accessory muscles
Effort of breathing/fatigue
Obvious chest injury
Ability to clear secretions by coughing
Sweating

LISTEN

From the end of the bed:
- Noisy breathing
- Coughing
- Ability to talk in complete sentences
Percussion:
- Dull, normal, hyper-resonant
Auscultation:
- Bilateral air entry
- Vesicular/bronchial breath sounds
- Crepitations, wheeze, rub
- Vocal resonance

FEEL

Pulse rate
Tracheal deviation
Chest expansion
Chest wall tenderness/injury
Surgical emphysema
Percussion note

The following table illustrates the examination findings of common respiratory problems.

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	Chest Expansion	Trachea	Percussion	Breath Sounds/added sounds	Vocal Resonance
Normal	Equal	Central	Resonant	Vesicular	Normal
Pneumothorax	Reduced on affected side	Shifted to affected side in simple, away from in tension pneumothorax	Hyper-resonant on affected side	Reduced breath sounds on affected side	Reduced on affected side
Pneumonia	Can be reduced on affected side	Central or shifted towards side of lobar collapse	Dull over affected zone	Reduced breath sounds, coarse crepitations, bronchial breathing over affected zone	Increased over affected zone
Pleural effusion	Reduced on affected side	Central or shifted away from affected side if large	Stony dull	Reduced/absent	Reduced over affected zone
Pulmonary Oedema	Equal	Central	Potentially dull bases (pleural effusions)	Fine inspiratory crepitations ranging from lung bases to throughout lungs	Reduced over affected zone
Asthma exacerbation	Equal but may be decreased if patient tired	Central	Normal	High pitched expiratory wheeze in severe attack	Normal
COPD exacerbation	Equal	Central	Resonant	Bilateral expiratory wheeze & crepitations	Normal
Pulmonary embolism	Equal	Central	Normal	Normal or localised crepitations / pleural rub	Normal

Pulse oximetry

Pulse oximeter probe on patient's finger.

A pulse oximeter measures oxygen saturations (sats or SpO₂). It is an essential tool in monitoring acutely ill and deteriorating patients. Oxygen saturation is related to the Arterial partial pressure of oxygen (PaO₂) by the oxygen dissociation curve. It is not a linear relationship but an oxygen saturation of 94% approximately equates to a PaO₂ of 8 kPa. If the PaO₂ drops below 8 kPa then a rapid fall in saturations occurs due to the shape of the oxygen dissociation curve. Normally oxygen saturations are > 94-98%, but patients with chronic respiratory disease may be used to significantly lower saturations (88-92%). A pulse oximeter does not detect hypercapnoea or acidosis therefore cannot be used to assess the adequacy of ventilation. An arterial blood gas (ABG) is required to measure the arterial partial pressure of carbon dioxide (PaCO₂).