Case of the Month
March 2006

22-year-old female — Shortness of breath

Dispatch

"Aid 5, Medic 1; 22-year-old female, shortness of breath"

En route your crew discusses the following causes of SOB in a 22-year old:

• asthma
• anaphylaxis
• hyperventilation syndrome

Dispatch updates you reporting that the patient has a history of breathing problems and cannot find her medicine.

Scene Size-up
You arrive at the scene and the patient's mother directs you into the house. She is very concerned and tells you of her daughter's history of asthma over the past several years. The daughter is visiting from college, became short of breath and cannot find her inhaler. The scene appears to be safe.

Initial Assessment
As you approach the patient you notice that she is sitting on a bed, leaning slightly forward and propping her upper body up by placing her hands on her knees. She appears tired and anxious. She looks up at you briefly as you enter then looks down again, focusing on her breathing. She is slightly pale and has cool clammy skin.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? Your course of action depends on your choice.

• What treatment does she need?
• What would you do to further evaluate her?
• Would you give a short report to the incoming medic unit?

Initial Treatment
You decide that the patient is SICK based on difficulty of breathing and body position.

You quickly advise the medic unit that you have "a SICK patient with shortness of breath and a history of asthma." You then begin oxygen therapy using a NRM at 10 liters per minute. Quickly you listen to her breath sounds while your partner gets the blood pressure and applies a pulse oximeter.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

As you continue to monitor the patient and await the medic’s arrival the mother looks for, and eventually finds, the patient’s inhaler. You quickly confirm that the inhaler is prescribed to the patient, check the expiration date and give is a couple gentle shakes. You hand her the inhaler and she is able to take two puffs. After a few minutes her shortness of breath becomes less severe, but her respiratory rate is still above 30 and her heart rate is unchanged. As you listen to her breath sounds again you feel that she might be getting air a little deeper into her lungs. Her oxygen saturation remains at 97%.

The medic unit arrives and assesses breath sounds again. Immediately one medic sets up an albuterol nebulizer while the other attaches a heart monitor. Since the patient has already started to respond favorably to the inhaler, they decide to allow her some time with the nebulizer instead of preparing for a rapid transport. After a few minutes with the nebulizer the patient is markedly better and more likely to tolerate being moved to the medic unit’s stretcher. Her pursed lip breathing has disappeared and she is able to speak in short sentences without a pause to breath.

Asthma
Asthma is a chronic disease, but for most people it’s effects are only experienced occasionally. During an attack, the airways in the lungs go through a three-phase process that progressively makes breathing more difficult. During the first phase the sides of the airways become inflamed and start to swell. As the airways become more irritated the muscles around them begin to tighten, further decreasing the amount of air moving in and out. Finally the linings of the airways start to produce excess mucus adding to the patient’s inability to breathe effectively. 

Due to the nature by which we breathe (the chest walls expanding and the diaphragm dropping) it is easier to get air into the lungs than it is to get it out. This is amplified in a person having an asthmatic attack. Rarely do they fail to get air in, but exhaling is extremely difficult.

As an asthma patient tries to exhale, the positive pressure placed on the airways by the contracting chest wall and diaphragm tend to collapse the airways further, trapping the air that is high in carbon dioxide in the distal reaches of the lungs.  Because of this, a person suffering an asthma attack usually has a high oxygen saturation reading, but the acidity of their system increases and the carbon dioxide cannot be properly expelled. This increased acidity further increases the respiratory rate resulting in the situation spiraling out of control.

The Lesson Learned from This Case
Treatment of asthma includes the administration of oxygen and the use of medications that will open the patient’s airways back up.

One of the most common and safest medications used is Albuterol. When Albuterol is made into a mist by an inhaler or nebulizer, and drawn into the patient’s lungs, it opens the airways to allow a better flow of oxygen in and, just as important, the flow of waste gases like carbon dioxide out.

Not so trivial question: Why do asthmatics purse their lips?
Sometimes you will see asthma patients with pursed lips so that, as the air leaves the lungs, a certain amount of back pressure will remain. This keeps the airways slightly more open during exhalation, thus "draining" more of the carbon dioxide and other waste gases.