Respiration Assessment in Emergency Care for EMTs

Table of Contents

Respiration in Emergency Medical Care

Why this matters: Breathing can deteriorate before blood pressure falls or cardiac arrest occurs. A respiratory rate, breathing pattern, chest examination and oxygen-saturation reading give the EMT an early view of ventilation, oxygenation and the work the patient is using to breathe. The goal is not to write down a number and move on; it is to recognise threatened airway, respiratory distress or respiratory failure early, support breathing safely and communicate the trend.

Learning outcomes

By the end of this lesson, the learner should be able to:

Define respiration, ventilation, oxygenation, perfusion, hypoxaemia and respiratory failure.
Measure and document respiratory rate accurately for a resting adult, child and infant.
Describe respiratory depth, rhythm, effort, chest expansion, breath sounds and airway noises.
Recognise respiratory distress, impending respiratory failure and respiratory arrest.
Use pulse oximetry correctly while understanding its limitations and the need to assess the whole patient.
Perform a focused history and examination for breathlessness, cough, wheeze, chest pain or abnormal breathing.
Provide safe first-line support within EMT scope and Uganda ambulance/facility protocol.
Reassess after every intervention, identify deterioration and give a precise respiratory handover.

1. What is respiration?

Respiration is the process by which the body moves air into and out of the lungs, exchanges oxygen and carbon dioxide across the alveoli, transports gases in the blood and uses oxygen at cellular level. It is often used as a broad term, but EMT assessment becomes clearer when the process is divided into linked steps.

Component	Meaning	Emergency question
Airway	Passage from nose and mouth through the pharynx, larynx and trachea.	Is air moving freely or is there obstruction, swelling, blood, vomit or a foreign body?
Ventilation	Movement of air into and out of the alveoli.	Is the patient moving enough air, or are breaths shallow, slow, tiring or absent?
Diffusion	Exchange of oxygen and carbon dioxide across the alveolar-capillary membrane.	Could pneumonia, pulmonary oedema, asthma or a collapsed lung impair exchange?
Oxygenation	Loading oxygen onto haemoglobin and delivering it to blood.	Is the saturation low, falling or falsely reassuring?
Perfusion	Blood flow that carries oxygen to tissues.	Is shock, anaemia or poor cardiac output limiting oxygen delivery despite a reasonable SpO₂?
Cellular respiration	Use of oxygen to produce energy and removal of carbon dioxide.	Could sepsis, poisoning or metabolic disease cause tissue hypoxia without obvious lung signs?

2. Key respiratory terms

Term	Working definition for EMTs	Important caution
Respiratory rate (RR)	Number of complete breaths in one minute.	Count for a full minute when irregular, distressed or in a child.
Respiratory depth	Approximate amount of air moved with each breath: shallow, normal or deep.	A normal rate with very shallow breaths may still mean inadequate ventilation.
Respiratory rhythm	Regularity and pattern of inspiration and expiration.	Periods of apnea, crescendo-decrescendo breathing and gasping are danger signs.
Dyspnoea	Subjective awareness of difficult or uncomfortable breathing.	Severity is determined by function, speech, appearance and physiology, not words alone.
Tachypnoea	Abnormally fast breathing.	May be compensation for hypoxia, acidosis, fever, pain or anxiety.
Bradypnoea	Abnormally slow breathing.	Think opioid or sedative toxicity, brain injury, hypothermia or exhaustion.
Apnoea	Absence of effective breathing.	Agonal gasps are not normal breathing; begin the resuscitation pathway.
Hypoxaemia	Low oxygen in arterial blood.	Pulse oximetry estimates saturation; it does not measure ventilation or carbon dioxide.
Hypercapnia	Raised carbon dioxide from inadequate ventilation.	A patient can have a normal SpO₂ while retaining dangerous carbon dioxide.
Respiratory distress	Increased effort or difficulty maintaining adequate breathing.	Distress can progress to failure; repeat observations rather than waiting for collapse.
Respiratory failure	Inability to maintain adequate oxygenation, ventilation or both.	Altered consciousness, exhaustion, cyanosis and abnormal gas exchange demand urgent escalation.

3. Why respiration is an early warning sign

Respiratory rate often rises before oxygen saturation falls or hypotension appears.
Increasing effort may indicate that the patient is using up respiratory-muscle reserve.
A falling rate in an exhausted patient can be worse than a high rate because it may signal fatigue.
Abnormal breathing can reveal airway obstruction, bronchospasm, pulmonary oedema, pneumothorax, sepsis, metabolic acidosis, poisoning or neurological injury.
Respiratory observations guide immediate positioning, oxygen decisions, airway support, transport urgency and frequency of reassessment.

“RATE – WORK – QUALITY – OXYGEN – TREND”
Count the rate, observe the work, judge the quality of each breath, check oxygenation and follow the trend.

4. Normal adult respiratory observations

For a calm adult at rest, many emergency teaching standards use a respiratory rate of about 12–20 breaths per minute. A high or increasing rate, especially above about 25 breaths per minute, is a warning marker rather than a diagnosis. Pain, exercise, fever, pregnancy, anxiety, altitude and conversation can temporarily change the rate, so document the context.

Observation	Expected resting adult finding	Concerning finding
Rate	Approximately 12–20/min	>25/min, rapidly rising, <8/min, pauses or absent breaths
Rhythm	Regular, smooth inspiration and expiration	Irregular, periodic, crescendo-decrescendo, gasping or silent periods
Depth	Moderate, comfortable chest movement	Very shallow, exhausting deep breaths or markedly unequal movement
Effort	Quiet breathing without accessory muscles	Retractions, nasal flaring, tripod posture, grunting or diaphoresis
Speech	Full sentences without pausing	Words only, single breaths, inability to speak or sudden silence
Colour and mental status	Usual colour, alert and oriented	Central cyanosis, pallor, agitation, confusion, drowsiness or collapse
Chest movement	Symmetrical rise and fall	Unilateral expansion, paradoxical movement or a flail segment

5. Paediatric and infant respiratory rates

Children normally breathe faster than adults. Count when the child is calm if possible, and use the age-specific Uganda/WHO IMCI or facility chart rather than applying adult thresholds. A crying child may have a temporarily high rate; persistent fast breathing, chest indrawing, grunting, stridor, cyanosis, poor feeding or altered consciousness is more important than a single number.

Age group	WHO/IMCI fast-breathing threshold commonly used	Critical accompanying signs
Young infant 0–59 days	≥60 breaths/min	Apnoea, grunting, severe chest indrawing, poor feeding, lethargy, cyanosis or fever/hypothermia.
2 months to under 12 months	≥50 breaths/min	Chest indrawing, stridor when calm, inability to feed, convulsions or oxygen concern.
12 months to under 5 years	≥40 breaths/min	General danger signs, severe work of breathing, altered consciousness or inability to drink.
Older child/adolescent	Use age-appropriate local chart; interpret with appearance and effort.	Silent chest, exhaustion, cyanosis, severe retractions or falling consciousness.

Paediatric safety: a slowing respiratory rate in a previously struggling child may indicate exhaustion, not recovery. Reassess chest movement, alertness, pulse and oxygenation immediately.

6. When an EMT should measure respiration

Every primary survey, especially after trauma, collapse or an unexplained emergency call.
Breathlessness, cough, wheeze, noisy breathing, chest tightness or pleuritic chest pain.
Fever, suspected pneumonia, sepsis, malaria with respiratory distress or severe infection.
Altered mental status, seizure, suspected stroke, head injury or spinal injury.
Overdose, alcohol or sedative use, opioid exposure or unknown poisoning.
Chest trauma, burns, smoke inhalation, drowning, electrocution or near-hanging.
Allergic reaction or suspected anaphylaxis.
Pregnancy, labour, postpartum collapse or a patient with known heart or lung disease.
Before and after oxygen, nebulisation, suction, airway positioning, assisted ventilation or medication.
Any patient whose condition changes, even if the previous reading was normal.

7. Preparing to count the respiratory rate

Complete a rapid visual assessment first. If the patient is apnoeic, gasping, cyanosed, severely distressed or unresponsive, support the airway and breathing immediately.
Position the patient safely. A conscious breathless patient often breathes best sitting upright; an unconscious breathing patient needs airway protection and a safe lateral position unless another injury requires a different plan.
Allow the patient to settle if the condition permits. Do not tell an anxious patient, “I am counting your breathing,” because conscious control can change the rate.
Observe the chest or abdomen discreetly while appearing to check the pulse. One rise and fall equals one breath.
Use a watch or timer. Count for a full 60 seconds when the rhythm is irregular, the patient is a child, the patient is very ill or the result will guide a major decision. A 30-second count multiplied by two is acceptable only when rhythm is regular and local policy allows.
Record rate, rhythm, depth, effort, position, oxygen device and patient activity at the time of measurement.

8. Counting technique: adult and child

Step	Adult technique	Child/infant technique
Observe	Watch chest or abdomen without prompting conscious control.	Watch abdomen or chest while calm; count before disturbing the child.
Count	One inspiration plus expiration = one breath; count for 60 seconds if irregular.	Count for a complete minute because pauses and variability are common.
Describe	Rate, regularity, depth and accessory muscle use.	Rate, chest indrawing, nasal flaring, grunting, feeding ability and colour.
Repeat	Repeat after intervention or if the value conflicts with appearance.	Repeat when the child is quiet; do not delay emergency support for a perfect count.

9. Assessing respiratory depth

Depth is a clinical estimate of the volume moved per breath. It is not the same as the oxygen-saturation number. A patient may breathe 30 shallow times per minute and move less air than a patient who breathes 15 comfortably deep times per minute.

Shallow: small chest movement, weak air entry, rapid fatigue or postoperative pain.
Normal: comfortable, symmetrical movement with a smooth inspiratory and expiratory phase.
Deep: large excursions; may be compensatory in metabolic acidosis, exercise or anxiety.
Very deep and laboured: consider DKA, severe metabolic acidosis, hypoxia or impending exhaustion.
Minimal movement: consider severe obstruction, neuromuscular weakness, opioid toxicity, fatigue or respiratory arrest.

10. Assessing rhythm and breathing patterns

Pattern	Description	Possible significance
Regular	Similar intervals and depth between breaths.	May be normal, but a regular abnormal rate still requires explanation.
Irregular	Variable intervals or depth without a predictable cycle.	Arrhythmia, neurological illness, pain, anxiety or respiratory compromise.
Cheyne–Stokes	Crescendo–decrescendo depth followed by an apnoeic pause.	Neurological injury, heart failure or severe systemic illness; report promptly.
Biot/ataxic breathing	Clusters of breaths with irregular pauses.	Possible medullary or raised-intracranial-pressure problem.
Kussmaul-type	Deep, laboured, often rapid breathing.	Metabolic acidosis such as DKA; look for dehydration and altered mentation.
Agonal gasping	Infrequent, irregular, ineffective gasps.	Cardiac arrest until proven otherwise; do not label as normal breathing.

11. Work of breathing

Work of breathing is the effort required to maintain ventilation. Compare the patient’s appearance over time. A calm patient who suddenly sits forward, sweats and recruits neck muscles is deteriorating even if the rate is only mildly elevated.

Sign	What the EMT may see or hear	Interpretation
Tripod posture	Sitting forward with hands braced on knees or a table.	Uses accessory muscles to improve ventilation; indicates significant breathlessness.
Accessory muscle use	Neck, intercostal or abdominal muscles visibly contracting.	Increased effort; may progress to fatigue.
Retractions	Skin drawn in above the sternum, between ribs or below ribs.	Marked negative pressure, especially important in infants and children.
Nasal flaring	Nostrils widen during inspiration.	Common sign of paediatric respiratory distress.
Grunting	Short sound at the end of expiration.	May help maintain alveolar pressure; concerning in infants and severe lung disease.
Paradoxical movement	Chest and abdomen move in opposite directions.	Severe fatigue, diaphragmatic dysfunction or flail chest.
Diaphoresis and agitation	Sweating, restlessness, inability to settle.	Possible hypoxia, hypercapnia, shock or high respiratory effort.
Silent chest	Very little air movement despite severe distress.	Potential critical obstruction or exhaustion; an ominous sign in asthma.

12. The “talk test”

Ask the patient to speak a short sentence. Speech requires controlled expiration and is a rapid functional test of ventilation.

Speech ability	Clinical meaning	Action
Full sentences	Breathing reserve appears adequate at that moment.	Continue full assessment; do not dismiss other abnormal signs.
Short phrases	Moderate breathlessness or reduced reserve.	Sit upright, monitor closely, assess oxygenation and cause.
Single words	Severe respiratory distress.	Urgent airway/breathing support and rapid transport.
Unable to speak, silent or altered	Impending failure, obstruction or exhaustion.	Immediate ABC response and advanced support request.

13. Respiratory distress, failure and arrest

Stage	Typical findings	Priority
Distress	Fast breathing, increased effort, dyspnoea, wheeze or mild hypoxaemia; patient still alert.	Identify cause, position, monitor, give indicated oxygen/support and reassess frequently.
Failure	Severe hypoxaemia, rising carbon dioxide, exhaustion, cyanosis, confusion, drowsiness, bradypnoea or silent chest.	Immediate airway and ventilation support, senior/advanced help, urgent transport.
Arrest	Absent normal breathing, gasping, no effective chest rise, loss of responsiveness.	Activate resuscitation, provide high-quality CPR and ventilation/AED per protocol.

Danger principle: A respiratory rate that becomes slower after a period of extreme effort may mean the patient is tiring. Never interpret a falling rate in isolation.

14. Primary respiratory assessment: look, listen and feel

Look: position, colour, chest movement, accessory muscles, secretions, inhalers, oxygen equipment and ability to speak.
Listen: patient’s words, cough, stridor, wheeze, gurgling, snoring, grunting and silence.
Feel: airflow at the mouth and nose, chest expansion, skin temperature, pulse quality and tracheal position when appropriate.
Measure: respiratory rate, pulse, blood pressure, level of consciousness, temperature and SpO₂ when a reliable signal is available.
Act: correct an immediately reversible airway problem and reassess before proceeding.

15. Pulse oximetry (SpO₂)

Pulse oximetry estimates the percentage of haemoglobin carrying oxygen and displays a pulse rate. It is useful for detecting and trending hypoxaemia, but it does not measure carbon dioxide, tidal volume, work of breathing or tissue perfusion. A reassuring number never overrides a patient who looks critically ill.

SpO₂ finding	How to interpret it	EMT response
Usual target range in a healthy adult	Often mid-to-high 90s at sea level, depending on the patient and device.	Interpret with symptoms, altitude, chronic disease and local protocol.
Falling or persistently low reading	May indicate hypoxaemia, poor signal, perfusion problem or device limitation.	Check the patient, sensor and waveform; support breathing and escalate.
<90% in a breathless patient	Serious hypoxaemia is likely, although thresholds and targets may differ in chronic lung disease.	Urgent ABC management, oxygen according to protocol and expedited transport.
Normal SpO₂ with severe distress	May be early disease, poor measurement, carbon-monoxide exposure or ventilatory failure.	Assess respiratory effort, mental state and ventilation; do not discharge based on SpO₂ alone.
Unstable or impossible signal	Motion, cold fingers, shock, nail products, poor perfusion or sensor placement.	Correct the signal and use clinical signs while repeating the reading.

16. How to obtain a reliable pulse-oximeter reading

Explain the sensor and ensure the patient is reasonably still.
Choose a warm, well-perfused finger, toe, ear or approved site. Remove nail coverings if they interfere.
Place the sensor correctly and wait for a stable pulse waveform or signal indicator rather than recording the first flashing number.
Compare the displayed pulse with the manually palpated pulse. A mismatch may indicate motion or poor signal.
Record the SpO₂, pulse rate, oxygen device/flow, patient position and clinical appearance.
Repeat after repositioning, oxygen, suction, bronchodilator or deterioration; record the trend.

17. Pulse-oximetry limitations

Motion, shivering, tremor, low perfusion, shock and cold extremities can create false or unstable values.
Dark skin pigmentation can contribute to occult hypoxaemia because some pulse oximeters may overestimate saturation; examine the patient and use blood-gas testing when available and clinically needed.
Carbon-monoxide poisoning can produce a misleadingly normal saturation because the sensor cannot reliably distinguish carboxyhaemoglobin from oxyhaemoglobin.
Severe anaemia may allow a normal saturation percentage while total oxygen content remains inadequate.
Peripheral vasoconstriction, dysrhythmia, nail polish, artificial nails, bright light and incorrect sensor placement may interfere.
Pulse oximetry says little about ventilation. A patient retaining carbon dioxide may have a normal SpO₂, especially after oxygen is applied.

Clinical rule: Treat the patient’s breathing and appearance, not a single oximeter number.

18. Inspecting the chest

Inspection point	Normal/expected	Abnormal clues
Chest shape	Symmetrical contour appropriate to age and body habitus.	Barrel chest, deformity, burns, wounds, swelling or severe kyphosis.
Rise and fall	Equal expansion on both sides.	Unilateral reduction, paradoxical movement, flail segment or splinting.
Skin	Usual colour and warmth.	Cyanosis, pallor, mottling, sweating, soot or circumoral colour change.
Posture	Comfortable at rest.	Tripod, orthopnoea, inability to lie flat or protective guarding.
Scars and devices	No urgent obstruction.	Tracheostomy, chest drain, oxygen tubing, inhaler or surgical scar.

19. Palpation and chest expansion

Use gentle palpation when the patient is stable and there is no reason to delay transport. Compare left with right rather than searching for a single “normal” feeling.

Place hands symmetrically on the lower chest and observe whether both sides move together.
Feel for tenderness, crepitus, subcutaneous emphysema, instability or a flail segment after trauma.
Assess tracheal position only when it can be done safely; deviation with severe distress is an emergency sign, not a diagnosis by itself.
Do not press heavily on a painful chest or remove dressings from an unstable patient simply to complete an examination.

20. Breath sounds and added sounds

Sound	Description	Possible causes / EMT significance
Normal vesicular	Soft, low-pitched airflow, inspiration longer than expiration.	Expected over most peripheral lung fields.
Wheeze	Musical, usually high-pitched sound from narrowed airways.	Asthma, COPD, allergic bronchospasm; a silent chest may be more dangerous than loud wheeze.
Crackles/crepitations	Discontinuous popping or bubbling sounds.	Pulmonary oedema, pneumonia, atelectasis or interstitial disease.
Stridor	Loud harsh sound, commonly inspiratory, from upper-airway narrowing.	Impending airway obstruction; keep the patient calm and call advanced help.
Rhonchi	Low-pitched coarse sounds that may change after coughing.	Secretions or larger-airway obstruction.
Pleural rub	Grating sound with respiration.	Pleural inflammation; report with pain and other findings.
Absent or markedly reduced	Little or no audible airflow on one or both sides.	Pneumothorax, pleural fluid, severe obstruction, shallow breathing or critical fatigue.

Do not delay lifesaving care for auscultation. A noisy upper airway, absent effective breathing, severe cyanosis or rapidly worsening effort takes priority over a complete chest map.

21. Focused respiratory history

Use the patient’s own words first, then clarify. A focused history can continue during transport after immediate threats are managed.

Question area	Questions to ask
Onset and time course	When did the breathing problem start? Sudden or gradual? What was happening at onset?
Provocation/position	Worse lying flat, walking, at night, in dust, after food, exercise, a new medicine or an insect sting?
Quality	Is it tightness, air hunger, pain on breathing, choking, noisy breathing or inability to get air in?
Severity/function	Can you speak full sentences, walk, feed, sleep or lie flat? What is different from usual?
Associated symptoms	Fever, cough, sputum, blood, wheeze, chest pain, palpitations, leg swelling, fainting or confusion?
Past history	Asthma, COPD, TB, pneumonia, heart failure, sickle cell disease, HIV, allergies, anaemia or previous intubation?
Medication	Inhalers, oxygen, diuretics, anticoagulants, opioids, sedatives, insulin or recent dose change?
Exposure	Smoke, carbon monoxide, chemicals, dust, infection, drowning, trauma, travel, immobilisation or pregnancy?

22. Focused secondary examination

Temperature and infection signs: fever, chills, focal pain, sputum and sepsis features.
Cardiovascular signs: pulse, blood pressure, capillary refill, oedema, jugular venous pressure if trained and relevant.
Neurological signs: anxiety, agitation, confusion, drowsiness, headache, speech and ability to protect the airway.
Extremities: unilateral calf swelling or tenderness, peripheral cyanosis, clubbing and signs of poor perfusion.
Medication and device check: inhaler technique, oxygen supply, tracheostomy, nebuliser or home ventilator.
Environmental clues: fire, fumes, pesticide, charcoal stove, overcrowding, sick contacts or a collapsed person in an enclosed space.

23. Tachypnoea: common causes

Cause group	Examples	Clues that help separate them
Airway/lung	Asthma, COPD exacerbation, pneumonia, pneumothorax, pulmonary embolism.	Wheeze, crackles, unilateral sounds, pleuritic pain, cough, fever or sudden onset.
Cardiac	Pulmonary oedema, heart failure, myocardial infarction or dysrhythmia.	Orthopnoea, frothy sputum, crackles, oedema, chest pain or risk factors.
Metabolic	DKA, lactic acidosis, renal failure, severe anaemia.	Deep breathing, dehydration, vomiting, shock, fatigue or abnormal glucose.
Systemic	Fever, sepsis, pain, pregnancy, heat illness or shock.	Temperature, perfusion, infection source, bleeding or pregnancy history.
Neurological/toxicological	Brain injury, salicylates, anxiety/hyperventilation or early opioid withdrawal.	Mental status, pupils, exposure history and other neurological signs.

24. Bradypnoea and inadequate ventilation

Opioid, benzodiazepine, alcohol or other sedative toxicity.
Post-seizure depression, head injury, stroke, raised intracranial pressure or brainstem disease.
Respiratory-muscle fatigue after prolonged asthma, COPD or severe infection.
High spinal cord injury, neuromuscular weakness or myasthenic crisis.
Severe hypothermia or metabolic depression.

Look for small tidal volumes, falling alertness, weak cough, snoring, cyanosis, rising pulse, abnormal pupils or a patient who can no longer maintain posture. Supplemental oxygen alone cannot correct inadequate ventilation; the patient may need airway opening and assisted ventilation under protocol.

25. Hyperventilation versus tachypnoea

Feature	Hyperventilation	Tachypnoea
Meaning	Ventilation exceeds metabolic carbon-dioxide production, often causing low CO₂.	Fast breathing; alveolar ventilation may be adequate, excessive or inadequate if breaths are shallow.
Possible causes	Anxiety/panic, pain, hypoxia, pulmonary embolism, sepsis or metabolic acidosis.	Fever, infection, asthma, pulmonary oedema, shock, pain or compensation.
Risk	Do not label as panic until life-threatening causes are considered.	Do not assume fast means effective; assess depth and mental state.
EMT approach	Calm reassurance while checking glucose, oxygenation, chest pain, pregnancy and red flags.	Treat the cause, support breathing and reassess trend.

26. Immediate positioning and airway support

For a conscious breathless patient without shock, allow the position of comfort, usually upright or leaning forward.
Loosen restrictive clothing, remove obvious environmental irritants and keep the patient warm but not overheated.
Open the airway with head-tilt/chin-lift unless cervical-spine injury is suspected; use jaw thrust and manual stabilisation when appropriate.
Suction visible secretions, blood or vomit when trained and equipped. Do not blindly sweep the mouth.
Use an oropharyngeal or nasopharyngeal airway only when indicated, trained and authorised; consider contraindications and patient tolerance.
Give oxygen when clinically indicated and titrate according to local protocol, target range, chronic lung disease status and response.
If ventilation is inadequate, prepare bag-valve-mask support and advanced airway assistance rather than waiting for saturation to fall.

27. Oxygen therapy principles

Oxygen is a treatment, not a routine comfort measure. Assess the patient before and after administration. Select the device that matches the need and the patient’s ability to breathe.

Device	Typical use	Safety considerations
Nasal cannula	Low-to-moderate supplemental oxygen in a cooperative patient breathing adequately.	Check fit, mucosal comfort and actual flow; a mouth-breathing patient may receive less benefit.
Simple face mask	Moderate oxygen when the patient is breathing spontaneously.	Do not use at very low flow that permits carbon-dioxide rebreathing; follow device policy.
Non-rebreather mask	High-concentration oxygen for significant hypoxaemia in a patient with adequate spontaneous ventilation.	Inflate reservoir before placement and monitor for fatigue; it does not provide ventilation.
Bag-valve-mask	Inadequate or absent ventilation with a trained provider and appropriate seal.	Use the lowest effective volume, watch chest rise, avoid excessive ventilation and use two-person technique when possible.
Nebuliser or spacer	Protocol-approved bronchodilator delivery for bronchospasm.	Monitor response, heart rate and fatigue; do not delay transport in severe distress.

Uganda practice: device choice, oxygen targets, flow rates and medications must follow the current ambulance, facility and medical-control protocol—especially for COPD, pregnancy, children and carbon-monoxide exposure.

28. Respiratory arrest and assisted ventilation

If the patient is unresponsive and not breathing normally, activate the resuscitation pathway. Gasping is not effective breathing. Open the airway, check for normal breathing for no more than the protocol’s specified interval, begin CPR/AED steps when indicated and ventilate with a bag-valve-mask and oxygen if trained.

Ventilation quality check	What to look for
Airway position	Head/jaw position maintains patency; mask is correctly sized and sealed.
Chest rise	Visible gentle rise, not forceful inflation or gastric distension.
Mask seal	No major leak; two-person technique improves seal when available.
Resistance	High resistance suggests obstruction, bronchospasm, poor position or equipment problem.
Patient response	Improved colour, pulse, chest movement and consciousness when circulation returns.

29. Asthma and COPD presentations

Look for wheeze, prolonged expiration, chest tightness, cough, tripod posture and inability to speak full sentences.
Ask about prescribed inhalers, previous ICU/intubation, triggers, recent infection and response to rescue medication.
Use the patient’s prescribed reliever or an authorised nebulised treatment according to protocol; assist technique without exceeding scope.
Monitor for exhaustion, decreasing air entry, drowsiness, cyanosis or a “silent chest,” which can indicate severe obstruction and impending failure.
Do not force a distressed patient to lie flat and do not delay transport while waiting for complete symptom resolution.

30. Pneumonia and sepsis-related breathing difficulty

Fever, cough, sputum, pleuritic pain, fast breathing and crackles may indicate pneumonia, but a patient can have severe infection without fever. Assess mental status, perfusion, urine output, temperature, glucose, oxygenation and the ability to drink. In children, chest indrawing, fast breathing, grunting, poor feeding or a general danger sign require urgent referral under IMCI-aligned local practice.

31. Pulmonary oedema and heart failure

Sudden breathlessness, orthopnoea, pink or frothy sputum, crackles, sweating, hypertension or a history of cardiac disease may indicate pulmonary oedema. Sit the patient upright, monitor closely, provide oxygen or positive-pressure support only as authorised, treat chest pain or shock according to protocol and transport urgently. Do not assume every wheeze is asthma; “cardiac asthma” can sound wheezy.

32. Pneumothorax and chest trauma

Sudden unilateral chest pain, breathlessness, unequal expansion, reduced breath sounds, hypoxia or shock after trauma suggests pneumothorax. A tension pneumothorax is a clinical emergency with worsening respiratory distress and circulatory compromise. Expose only as needed, seal an open chest wound with the approved dressing, support oxygenation and follow the trauma protocol for immediate decompression by an authorised clinician. Never delay transport to complete a lengthy examination.

33. Pulmonary embolism

Consider pulmonary embolism when breathlessness or pleuritic chest pain begins suddenly, especially with tachycardia, syncope, haemoptysis, unilateral leg swelling, recent surgery, prolonged immobility, pregnancy/postpartum state or previous thrombosis. SpO₂ may be normal in a smaller embolus. Support ABCs, avoid unnecessary exertion, monitor continuously and arrange urgent transport.

34. Anaphylaxis and upper-airway obstruction

Finding	Concern	Immediate priorities
Hoarse voice, stridor or throat tightness	Upper-airway oedema.	Call for advanced help, keep patient calm, avoid unnecessary airway manipulation and follow anaphylaxis protocol.
Wheeze, cough or respiratory distress	Lower-airway bronchospasm.	Position of comfort, oxygen if indicated and authorised emergency medication.
Rash, swelling, vomiting or collapse	Systemic allergic reaction with possible shock.	ABCDE, circulation support, rapid transport and repeated reassessment.
Sudden choking with ineffective cough	Foreign-body airway obstruction.	Use the age-appropriate choking algorithm; prepare for CPR if unresponsive.

35. Opioid or sedative poisoning

Slow, shallow or absent breathing with reduced consciousness and abnormal pupils should trigger a poisoning response. Protect the airway, provide ventilation support, check glucose, look for drug containers and ask witnesses what was taken. Administer naloxone only under the authorised protocol, then continue observation because respiratory depression can recur after the patient wakes.

36. Metabolic and neurological causes of abnormal breathing

Deep rapid breathing in DKA, renal failure or lactic acidosis is compensation; do not suppress it with sedatives.
Stroke, intracranial haemorrhage or raised intracranial pressure may produce irregular patterns and altered consciousness.
Severe anaemia can cause dyspnoea and tachycardia even when SpO₂ is normal.
Carbon-monoxide exposure can produce headache, confusion, collapse and a falsely reassuring pulse oximeter; remove from the source and follow the poisoning protocol.
Hypothermia, sepsis, fever, pain and panic can all change respiratory rate, but dangerous causes must be excluded before reassurance.

37. Special considerations in children

Keep the child with the caregiver where safe, minimise agitation and assess breathing while the child is in the position of comfort.
Count a full minute; crying and movement can make a short count misleading.
Look for nasal flaring, head bobbing, grunting, chest indrawing, poor feeding, lethargy, cyanosis and pauses.
Use child-sized oxygen equipment and age/weight-based protocols. A normal adult SpO₂ target or adult medication dose must not be assumed.
Infants may deteriorate rapidly because they have small airways and limited respiratory reserve; arrange early transport and advanced support.

38. Pregnancy, older adults and chronic lung disease

Group	Assessment issue	Practical approach
Pregnancy	Baseline ventilation and oxygen demand change; PE, asthma, aspiration and DKA are important differentials.	Position to support maternal breathing and circulation, use pregnancy-safe protocols and transport early.
Older adult	May have blunted fever, weak cough, atypical infection or silent hypoxia.	Compare with baseline, ask caregivers and examine mental status, function and perfusion.
COPD or chronic hypoxaemia	Usual saturation may be lower, but acute deterioration remains dangerous.	Use the patient’s prescribed target or local protocol; titrate oxygen and monitor ventilation.
Neuromuscular disease	Weak cough and fatigue can cause ventilatory failure before obvious cyanosis.	Assess speech, cough, secretion handling and mental status; seek advanced support early.

39. Reassessment after respiratory intervention

Reassessment is an intervention in its own right. Repeat the same observations after positioning, suction, oxygen, bronchodilator, antidote, assisted ventilation or fluid treatment.

Compare	Document	Escalate when
Rate and effort	RR, depth, rhythm, accessory muscles and ability to speak.	Rate rises, patient tires, effort increases or breathing becomes slow/irregular.
Oxygenation	SpO₂, signal quality, oxygen device/flow and skin colour.	SpO₂ falls, waveform unreliable or cyanosis/altered state persists.
Ventilation	Chest rise, air entry, cough strength and mental state.	Shallow breaths, rising drowsiness, poor cough or inadequate chest movement.
Cause and response	What was done, when, and how the patient changed.	No improvement, recurrence, new chest pain, shock or new focal findings.

40. Documentation and handover

Element	Example of a useful record
Initial appearance	“Sitting upright, anxious, speaking four-word phrases, intercostal retractions.”
Rate and pattern	“RR 32/min, regular, shallow; repeat 38/min after walking to stretcher.”
Oxygenation	“SpO₂ 88% on room air, reliable waveform; 94% on prescribed device at recorded flow.”
Chest findings	“Widespread expiratory wheeze, equal expansion; no stridor.”
History	“Asthma, ran out of reliever, symptoms began 2 hours ago after dust exposure; no chest pain.”
Intervention and response	“Positioned upright, authorised bronchodilator given at 15:10; phrases improved, RR 26/min at 15:18.”
Handover concern	“Still tiring and requires close monitoring; no safe discharge plan.”

41. Clinical scenarios for EMT practice

Scenario 1 – asthma deterioration: A 19-year-old is upright, speaking one word at a time, RR 34/min and wheezing. After treatment, the wheeze becomes quieter but the patient is drowsier and air entry is poor. This is not necessarily improvement; suspect exhaustion or a silent chest, support ventilation and transport urgently.

Scenario 2 – opioid toxicity: A patient is difficult to rouse, RR 6/min, shallow, SpO₂ 93% after oxygen and pupils are very small. The saturation does not make ventilation adequate. Open the airway, assist ventilation, follow the authorised antidote pathway and reassess for recurrence.

Scenario 3 – child with pneumonia: A 2-year-old has cough, RR 48/min while calm, lower-chest indrawing and poor drinking. Apply the age-appropriate IMCI danger assessment, support oxygenation, avoid unnecessary agitation and arrange urgent referral.

Scenario 4 – pulmonary oedema: An older adult cannot lie flat, is sweating and has crackles with pink frothy sputum. Sit upright, monitor circulation and oxygenation, use authorised support and transport urgently; do not assume wheeze means asthma.

Scenario 5 – chest trauma: After a motorcycle crash, the patient has sudden dyspnoea, unilateral reduced expansion and falling blood pressure. Treat as a life-threatening chest injury, support breathing, follow trauma protocol and request authorised decompression support.

Scenario 6 – normal SpO₂, serious illness: A charcoal-burner has headache, confusion and weakness with a normal pulse-oximeter reading. Suspect carbon-monoxide exposure, move to fresh air, administer oxygen according to protocol and arrange urgent transport.

42. Common mistakes to avoid

Counting respirations while telling the patient exactly what is being measured.
Using a 15-second count in an irregular, paediatric or critically ill patient.
Recording only the rate and ignoring depth, rhythm, effort, speech and mental status.
Trusting a single SpO₂ number without checking the waveform, perfusion and patient appearance.
Giving oxygen without recording the device and flow or reassessing the response.
Calling a distressed patient “anxious” before excluding asthma, PE, sepsis, DKA, poisoning or cardiac disease.
Assuming a slower respiratory rate is improvement when the patient is tiring.
Forcing a breathless patient flat or leaving a child alone during assessment.
Delaying transport for a complete chest examination when immediate airway or ventilation support is required.

43. EMT respiratory checklist

Observe	Measure	Act and reassess
Position and speech	RR for full minute when needed	Open airway and position safely
Chest rise and symmetry	Depth, rhythm and effort	Give oxygen/support per protocol
Colour, sweating and mental state	SpO₂ with waveform and pulse comparison	Suction or assist ventilation when indicated
Airway noises and breath sounds	Pulse, BP, temperature, glucose when indicated	Repeat after every intervention
Clues to trauma, poison or infection	Time, device, flow and trend	Escalate and transport early when unstable

44. Revision questions

Define respiration, ventilation and oxygenation.
Why can a normal SpO₂ coexist with dangerous hypoventilation?
What is the expected resting adult respiratory-rate range commonly taught in emergency assessment?
Why is a full-minute count important in children and irregular breathing?
List five signs of increased work of breathing.
What does inability to speak full sentences indicate?
How can a falling respiratory rate signal deterioration?
Describe Cheyne–Stokes, Kussmaul and agonal breathing.
What is the difference between respiratory distress and respiratory failure?
List three causes of tachypnoea.
List three causes of bradypnoea.
What are the WHO/IMCI fast-breathing thresholds for a young infant, an infant and a child aged 12 months to under 5 years?
Why should the patient’s own position of comfort usually be respected?
What makes a pulse-oximeter signal unreliable?
Why can carbon-monoxide poisoning produce a misleadingly normal SpO₂?
What does a silent chest mean in severe asthma?
Which breath sound suggests upper-airway narrowing?
Why must wheeze not automatically be labelled asthma?
What are the first priorities for suspected opioid-related respiratory depression?
Why is a child with chest indrawing and poor feeding high risk?
What findings suggest pulmonary oedema?
What are key clues to pneumothorax after trauma?
Why should oxygen device and flow be written in the handover?
What should be reassessed after bronchodilator, oxygen or assisted ventilation?
When should the EMT request advanced help immediately?

45. Key takeaways

Count respiratory rate accurately, but always add depth, rhythm, effort, speech, colour, mental state and chest movement.
Adult resting RR is commonly about 12–20/min; a high or increasing rate is an early illness warning.
Use WHO/IMCI age-specific thresholds for children and never apply adult cut-offs to infants.
Pulse oximetry is helpful but cannot measure ventilation and may be misleading in poor perfusion, carbon-monoxide exposure or deeply pigmented skin.
Oxygen supports oxygenation; it does not replace airway opening or assisted ventilation when breathing is inadequate.
Silent chest, exhaustion, altered consciousness, cyanosis, gasping or inability to speak are emergencies.
Reassess after every intervention and hand over the trend, not merely one number.

46. References and further reading

Scope note: This lesson supports EMT learning and examination preparation. Follow current Uganda Ministry of Health, ambulance-service, facility and medical-control protocols for oxygen targets, paediatric care, nebulised medicines, antidotes, airway devices, decompression, CPR and transport decisions.