The Ultimate Guide to EMT Vital Signs

Part 4: Respiration

Sillouette of Asthma

The respiratory vital sign rounds out our “big three” vital signs. (Pulse and blood pressure being the other two.) It is, quite possibly, the most misunderstood and overlooked of the big three vitals.

Two big problems we encounter when factoring in the respiratory component of the vital signs are:

1) We’re comfortable fibbing about the true respiratory rate. More so than pulse or blood pressure, respirations encourage us to violate the first rule of vital signs. Especially when the patient is in no apparent distress. We look at the patient, we make up their respiratory rate and, quite often, we’re wrong.

2) We fail to recognize the relationship between rate and volume. In EMT school we are rarely asked about the respiratory volume. We perform our scenarios. We count a rate of respiration. We report it. The scenario moves on. In the process we forget that respiratory rate is only half of the breathing equation. Without volume, the rate means very little to us.

With those two common errors in mind, let’s talk about obtaining an accurate respiratory rate and then let’s talk about truly assessing the quality of the patients respirations. Consider this your quick guide to respiration assessment mastery.

1) Assessing the True Respiratory Rate

Maybe we’d see less fibbing on the patients documented rate of respiration if we just admitted that the true respiratory rate isn’t as important as you may have been lead to believe. I confess; I rarely count a respiratory rate while I’m on scene with the patient.

Asthma

What’s more important than finding the exact respiratory rate is your ability to recognize if the patient is breathing normally, or abnormally fast, or abnormally slow. With that in mind, try this. Look. Yes…just look. Instead of waiting until you have a moment to hold up your watch and count a respiratory rate, simple get in the habit of looking at your patient and asking yourself, “Are they breathing to fast, or to slow or just right?” Then act.

Consider the patients age, their fitness level and other factors like recent exertion, ambient temperature and emotions like anxiety and anger. The respiratory center is sensitive to all these factors.

When it’s time to take a real-deal, documentable respiratory rate, find a moment when you can delegate a task to another provider, then step back and watch. I know that it’s common to teach people to pretend that they’re taking a pulse while they watch the respirations. This patient care head-fake always seemed a bit awkward to me. I just feel like I’m giving the appearance of taking a ridiculously long time to take a pulse. (Remember that I’m the guy that advocates for the three second pulse check.)

You might find that taking a moment to step back and just watch the scene progress while you partner and crew perform some task really improves your scene awareness. While you’re taking that 30 seconds to count the respirations, glance around and see what you might have missed while you were engaged in direct patient assessment.

If your patients respiratory rate is abnormally fast (tachypnea) you can get a pretty accurate idea of the true rate by counting for 15 seconds. Patients with respirations below 20 breaths per minute will fool you if you don’t take a full 30 second sample.

2) Assessing the Quality of Respiration

Minute volume is the volume of air the patient inhales and exhales over a one minute time frame. Do you remember the minute volume equation you learned back in EMT class? Here, don’t hurt yourself:

Respiratory Rate  X  Tidal Volume = Minute Volume

We didn’t teach you that equation with the idea that you were going to go out and get a spirometer and start documenting minute volumes on your patient care report.

The reason we made a big deal out of minute volume was to drive home the point that respiratory rate was only half of the respiratory equation. You can’t expect to count the respiratory rate and be done with your clinical decision making process. This misconception is often demonstrated by the very common EMT class question, “At what respiratory rate should I start bagging the patient?” My answer is always a resounding, “It depends!”

Imagine I asked you to tell me the value of Y in this equation:

5 + X = Y

You’d probably say, “Steve, I don’t have enough information.” (OK the wise-guy Algebra dude in the room might reply X+5, but nobody likes that guy.) You can’t tell me the real value of Y because you only have half of the equation. In the same way, I can’t tell you when to start bagging a patient based on respiratory rate alone (usually) because it’s only half of the equation. I also need to know about the volume of air being moved with each breath. I need to know about the quality of respiration.

So how do we figure that out? I’m glad you asked.

1.) Look at the patient’s posture.

I put this one first because it should be the first thing you instinctively evaluate as you’re approaching a patient with respiratory difficulty. How are they sitting? (Or standing or laying.) People with advanced shortness of breath don’t sit in a relaxed repose. They sit forward, often leaning on their knees. (Tripoding.) They prefer their legs down. And they don’t lay flat on their back unless they are doing pretty good or they are nearing the point of intubation. It won’t take you long to decide which side of the spectrum they’re on.

2.) Look at their chest.

If the patient has relaxed, normal respirations, you won’t see very much chest wall movement. But if they’re working to breathe, you can tell if they are getting a good, equal expansion with each breath. Does the chest wall move with each breath or is much of the effort wasted?

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Also not how they use their muscles. When they breathe in does the area above their clavicles retract? How about between the lower ribs out near their sides? How much effort does each breath take? How long do you estimate they can sustain that effort?

Also remember that our obstructive patients aren’t fighting to breathe in as much as they are fighting to breathe out. Pay attention to the effort of exhalation. Beware the patient who is getting tired of breathing.

3) Listen to their lungs.

I know, I know. Some people still like to argue that lung sounds aren’t an EMT skill. Forget those people. You’re not going to get in trouble for using your stethoscope like a stethoscope. Listen to the anterior chest, just below the armpits and on the back, both between and under the scapula.

If you’re new to the lung sound scene, listen to a lot of lung sounds. The best way to differentiate poor air movement and abnormal lung sounds is to hear lots of normal lung sounds first. Don’t make the error of ignoring lung sounds on patients who are breathing normally. Learn what normal lungs sound like. Then the abnormal sounds will make more sense.

Now you’ve got the whole equation. The whole kit and caboodle. The whole story. Go forth and assess some respirations. Hopefully, the next time you evaluate and report the patient’s respiratory status, you’ll be talking about more than just a number.

Now it’s your turn: Do you have any tips or tricks for becoming a respiratory master? Leave a comment and pass your knowledge on to the next guy (or gall) Thanks for coming.

Read More of the Vital Sign Series:

Part One: The Pulse

Part Two: The Blood Pressure

Part Three: The First Rule of Vital Signs

Comments

  1. Bruce Saunders says:

    Great post Steve,
    Respiratory rate is possibly the most neglected vital sign. One thing I’d like to add is that it can be well worth feeling the chest expansion (as long as it’s patient appropriate!) by actually putting both hands on each side of the patients chest -mid axillary line, over the lower ribs- and feeling for good chest expansion. Not only can you feel the chest move (good in low light situations, or with very shallow breathing) but sometimes you will literally feel the wheeze, rales or rhonchi through the chest wall.

  2. Not so much a tip, but some added information:

    With pediatrics, get them naked from the waste up. Pay more attention to their belly than their chest when looking for effort and rate. Also, nasal flaring along with retractions may indicate decreased pulmonary compliance. They can and will decompensate rather quickly.

    With adults who have obstructive airway disease, pay close attention to their mouth. If they “purse” their lips, they are having a hard time exchanging their waste CO2 for O2 within the capillary bed surrounding their alveoli. This purse-lipped breathing is an indication that they need PEEP (positive-end expiratory pressure). We give artificial PEEP with devices like C-PAP or BiPAP. Think of their alveoli as small paper bags that want to deflate every time they exhale. To keep the bags inflated, they breathe out as if they were breathing through a straw. This keeps a residual pressure within their lungs. Chronic lung diseases that cause this type of breathing may lead to the development of a “barrel chest”. The two are often synonymous.

    Great post Steve!

    -Adam

  3. Very good, helped me tons!

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  1. […] started with another installment of the ultimate guide to EMT vital signs. This month we looked at respiration. Then I took another run at the controversial phrase, “Patient’s define their […]