In today’s micro lecture, Australian Paramedical College Hon. Snr. Lecturer Sam Willis discusses respiratory system assessment and its importance as a Paramedic to do it as part of both the primary and the secondary survey.
In this lecture we’re going to talk about respiratory system assessment. Now, the reality is that respiratory system assessment is one of the most important skill sets that you can develop as a paramedic, because you will be basically assessing the respiratory system on every single patient. So for example, it’s not like a nervous system assessment, or an abdominal assessment that you only generally conduct if you’re suspecting a problem in that area. For a respiratory system assessment, you will be doing this as part of both the primary and the secondary survey.
So, let’s talk firstly about the typical situations that you’re going to find yourself in. So, you’re being dispatched to a private address for a 26 year old female complaining of difficulty in breathing. On arrival, you are greeted by have friends who were all panicked, and the female is clearly having difficulty in breathing and has a fast respiratory rate. So, it’s not unusual, uncommon for us paramedic to be called to this type of situation. Don’t automatically think that every single case you go to will be some longterm chronic metabolic disease because it can also be psychological people with anxiety, people with mental health problems. That’s why we always encourage our students to go into every situation with an open mind and try not to put the type of case you’re going to be going to into a tiny box because otherwise you can get caught out.
So, a 26 year old female complaining of difficulty in breathing. Now, regardless of the age, regardless of the situation, anybody who’s having difficulty in breathing will find it really scary, really frightening. And of course if the breathing problem continues for too long you can end up with a respiratory alkalosis. In other words, you can end up with the pH of your blood changing, so they are quite life threatening. So as the paramedic, it’s your role to identify the causes of the breathing problem, to calm the patient and to try and monitor any other type of situation, and so caring to bring them back to a normal state. Now, as part of this session, we’re also going to talk about the importance of doing a proper and thorough respiratory system assessment as well as the different stages, and I’m going to give you a bit of a pneumonic as well to help guide you in your respiratory assessment. And of course, we are also got to finally talk about the importance of documenting your clinical findings.
So, we’ve hinted to the fact that as the paramedic, you’ll be sent to assist many people who complain of difficulty in breathing, not just asthmatic patients and not just people with heart failure, not just people with acute mental health problems, but also trauma patients and other chronic conditions that don’t impact on the respiration system. Remembering that the breathing will become fast at any opportunity that the body needs extra oxygen, so it’s pretty complex and that’s why we need to have a really good understanding of this. The paramedic should be able to assess a patient’s respiratory system at several stages in the cycle that includes the primary survey, the secondary survey, as well as being able to monitor it all the while you are with that patient, because things can change just like that.
They must be able to draw upon knowledge and skills to be able to safely provide the right level of care, so you have to have a good understanding of the underpinning anatomy and physiology. You have to have a good understanding of how we breathe. We also have to have a good understanding of how the CO2 and the pH of the blood is measured and monitored by the body, because that way you can have an understanding of why it’s important to measure it and be able to control it. A respiratory system assessments should be carried out at least two places, not just two places. The first stage of the primary survey, then the secondary and a more thorough assessment is the secondary survey. So, the primary survey, really is just your A’s, B’s and C’s to try and eradicate anything that’s going to kill your patient quickly. So this is something we’ve said several times now, a primary survey, secondary survey.
So you’ve arrived on scene at this 26 year old female and this is what you’re doing. So you’ve done your danger, you’ve done your response to the patient’s airways, patents and clear. Then you’re looking at the breathing, you’re looking for the absence or presence. Yes, definitely she’s breathing. You’re looking at the rate, now you can determine this just by looking at the top part of the chest and counting if it’s regular over a period of 15 seconds. Now that might be difficult to do if she’s not breathing regularly, she’s panting and screaming and crying. Now with experience, you’ll be able to look at a person’s, right? And just make a rough ballpark figure. However, you don’t really, you can’t really draw on those skills until you’ve had many, many years experience and practice of risk assessing respiratory rate. So like any skill, the more you do it, the better you will become.
You’re looking at the effort of the chest rise and fall. In other words, is it really intense or is it short, and sharp, and shallow? Both of those mean different things. And then of course, finally you’re considering any added sounds that require investigation. So, when you’re listening to the chest, the only thing you should ever hear is, A, you should never hear any crackling and wheezing or anything else. Those noises are called added sounds. So when you’ve assessed the patient, and you’ve determined that her ABC’s are all okay, because if they’re not, let’s take for example the girl in this case study. You really need to be worried about that rate if it’s over 20 breaths per minute. Now what you will need to do is first determine what’s happened. The history will help you with this. You can ask either the patient, or the bystanders because if she’s particularly having difficulty in breathing, you want try and focus on keeping her breathing down.
The way you do this is to ask her to breathe in through the nose. Hold it for three seconds, one, two, three, breath out through the mouth. You can do that with her and you can do that about 10 times, but genuinely speaking, that will only work if the environment is calm and if it is a genuine anxiety attack, because let’s say she’s had trauma, then therefore you could be looking at a tension pneumothorax or something completely different. So history taking is really, really important. Okay. Secondary survey then, let’s say her breathing is fine, and you’re now moving into the part where you need to do a respiratory assessment, because you’re suspecting that there’s some prescription problem, what we use is inspect, palpate, percuss and auscultate.
Inspect. Now in an ideal world, you need to expose the pace that patient in a confidential and carefully thought out manner so that you can have a look. You’re looking for any signs of trauma, any signs of bruise, you’re looking for symmetry and making sure both sides move up and down at the same time. They’re both doing it at the same rate rather than in and out. You’re looking to make sure there’s no trauma to the chest where one part moves up and down, and the other doesn’t, and remembering you’re looking at the lateral thorax as well, which is if you know where your lungs are, they’re both posterior, anterior and medial as well. And, you’re looking at the posterior thorax and again you’re looking for right, you’re looking for absence and presence of trauma, and you’re looking for depth, and efficiency of breathing.
Palpation is a process that you can use to help you to decide if the both left and right sides are moving up at the same time. As you can see in this image here, the physician or in this case you the paramedic has placed up their hands at the lower portions of the lungs, to ask the patient to take a deep breath and the hands will at the same time, lift upwards and outwards, as you can see on this image. Percussion is a process of basically tapping on the finger. You can see that this physician is just tapping to make a sound. We use the word resonant to me normal. We also use hyper resonant, meaning lots of air, and we use the word dull to mean solid. So, in the lungs you should only ever hear a resonant sound, if there’s any hyperresonance on one side then there’s obviously extremes amounts of air in there, which could be air trapped by attention in the thorax, for example. Or if there’s a dull sound, if you tap onward then that’s also solid, so there shouldn’t ever be anything dull inside the lungs. If there is, you’re looking at some kind of chest infection or mucus buildup.
And then finally auscultation then. Auscultation is the process of putting a stethoscope on the patient and as we [inaudible 00:08:44] percussion, yes, you’re comparing the left side to the right side. So, here you can see on the anterior you are listening above the cover calls, you are comparing left and right. You are moving down, and you’re listening for the different sounds and then you’re doing the same on the posterior side on the back. Remembering to avoid the clavicles here, because you’re going to not hear anything over the lungs if you’re listening over bone. Just a brief look at these different sounds, hear. Vesicular sounds are heard over the large airways down here. Well, I say large, they’re not the largest, the largest airways are at the top, and you’ve got a large inspiration, short expiration. Bronchial sounds are heard lower down around here around the bronchitis, and they are short and sharp inspiration.
Bronchial vesicular around this part here on this region and they are … These are normal breath sounds. Then you’ve got fine crackles, which are small amounts of fluid in the lower basis of the lungs. Cost freckles are larger amounts of fluids. A wheeze is a, as you know, on expiration is asthma because your air is been forced through a constricted vessels and bronchi is an abnormal, continuous low pitched gurgling sound, which can be caused by infection. And anytime you guys can go onto YouTube and take a look at those sounds and have a listen for yourself. Now, documented and communicating findings is so important, not only because the hospital need to know what you found and once you’ve left, they may want to come back and review the patient later. But also, the things that you document will stay on file for 10 years and if it’s not documented, it didn’t happen as simple as that.
So all outcomes should be documented on the patient care record, even if you find nothing, put it on the patient care record, no abnormal sounds, no abnormal respiratory sounds on auscultation because that shows that you’ve undertaken the assessment. And of course, don’t forget to physically and verbally report your findings to the ED stuff. They will need a copy of that. Okay. So we’ve had a look at the importance of undertaking a respiratory assessment and the different stages in performing the assessment, when and where, and how, and the recognizing the needs of documenting the findings.