# Coaching Respirations



## Gbro (Oct 14, 2007)

Being this is the BLS forum I will direct this question mostly towards what is common in my area.
The page is for an elderly male, Complaining of chest Pain.
This Pt. is close to your position and instead of responding to the Rig, you go directly to the Pt. residence. You announce on your portable that you are on scene. 
You arrive at you Pt. and he is sitting upright gasping for air, You ask about the pain and pt. is so anxious he is barley able to talk. Pulse is 110, Resp. 32 using accessory mussels. You can hear the rales(congestion) in his voice. Your crew is still 2-3 min. out and you have gloves and a pocket mask.

Where do you start?


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## seanm028 (Oct 15, 2007)

Put him in a position of comfort and try to calm him until the crew arrives.  You shouldn't assist respirations with a pocket mask, should you?

Once the rig arrives you can start O2 via NRB and, if needed, assist with a BVM.  In the meantime, you can finish ABCs, maybe perform a focused physical exam.


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## Gbro (Oct 15, 2007)

Thank you for posting.
The pocket mask is a barrier if CPR is required. 
What i am looking for is Respiration Coaching Techniques.
This is a situation anyone could face, and for a long time depending on the cercumstances. (Say you are out hiking, or camping in the boundry waters).


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## seanm028 (Oct 15, 2007)

Oh, I see what you're asking.

Honestly, I don't really know.  I would just try to calm him down.  I'm sure someone out there has run across this before?


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## VentMedic (Oct 15, 2007)

Many times when the person is breathing rapidly, the body is trying to compensated either for a V/Q mismatch (oxygenation or ventilation) problem or an acid-base problem.  The person must maintain an overall minute ventilation determined by the body to stay alive. 

The respiratory system is the body's first line attempt at normalizing the body.

Ex.  Ketoacidosis - DKA - The pathogenesis of DKA is mainly due to acidosis. Excessive production of ketone bodies lowers the pH of the blood; a blood pH below 6.7 is incompatible with life. In order for the body to survive it orders Kussmaul breathing to blow off the CO2 and raise the pH.  If a person tires and can no longer effectively keep up the rate and depth of respiratory effort to maintain a pH compatible with life, patient dies.  Pet peeve is hearng some one tell the patient to slow down their respirations during a DKA crisis. This only demonstrates a lack of knowledge of what the body is trying to do. Focus at that time should be starting the treatment quickly and let the body do its thing.  Even with the modern ICU ventilation technology, the body is still better until definitive treatment is done to correct the situation. 

Biot's breathing is another which is often the result of increased intracranial pressure. You can not effectively "coach" a patient out of something the body is trying to correct or respond to. 

Pulmonary Emboli - In all cases of PE, ventilation/perfusion (V/Q) mismatch occurs to some degree, in which continued ventilation of lung units without circulation is present. Oxygenation is usually not affected by the V/Q mismatch, in contrast with V/Q mismatch that arises from obstruction of airways and lung parenchyma. Impaired oxygenation in the context of suspected PE implies a massive obstruction. 

An increase in effective alveolar dead space is a direct result of the V/Q mismatch. Ventilation (carbon dioxide removal) is usually compensated for by tachypnea. 

Pneumonia - Poorly ventilated areas of the lung may remain well perfused, resulting in ventilation/perfusion (V/Q) mismatch and hypoxemia. Tachypnea and hypoxia are common.  The body agains tries to compensate by trying to move more air (oxygen) to that area.

PCP or pneumocystis pneumonia patients will often present with extreme tachypnea and at the BLS level, high flow NRBM will be the only thing you can offer them. They will probably still over breathe the flow on the 15 L mask because their minute ventiation requirement might be 25 L/ minute.

Chest Pain - all depends on the etiology of the pain. This presents many reasons for tachypnea that the body may be trying to compensate.  The simplest cause, pain whether muscular or otherwise, may have to be alleviated first by some means either position of comfort, oxygen or pharmocologically.  If there is a V/Q mismatch problem or cardiac output problem, then that will have to be dealt with but will probably require more diagnostics then available to you. 

Good overview:

http://www.son.washington.edu/cne/conf/handouts/Lee.pdf

So, the way to "coach" a patient's respiration is to understand the pathophysiology of the disease process and why the body is wanting to breathe in that pattern.  Altering the body's compensation process to a "text book norm" may lead to a rapid decompensation of the patient.  Observe the patient to get a feel for what their overall minute ventilation requirement is and then you may be able to help them maintain that level more effectively.


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## BossyCow (Oct 15, 2007)

I've 'coached' respirations for anxiety patients who are hyperventilating and for some mild asthma attacks but I'm not sure I would with this guy.  I'd start with some heavy reassurance, lots of eye contact, as there may be an anxiety component to the problem.  (Not breathing makes people anxious) I've found that telling pt's the ambulance is on its way with the O2 and then starting with my assessment will sometimes calm the anxiety.  Without further info,  OPQRST on the pain, Skin color, cap refill etc.  Not much else to go on. No BP cuff with you?


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## VentMedic (Oct 15, 2007)

I will add a couple more things to my previous post.

Of course there is professional reassurance or assurance that you are a professional, whichever the case might be.  

A professional reassuring attitude during assessment is important to see if there is a change in the breathing pattern and "filter" out the anxiety factor to determine how the body actually wants to breathe.

During conversation, if it appears the patient is still trying to continue the same breathing pattern while speaking and picks up with the same pattern immediately after you try to interrupt the pattern, then the body is trying to correct something and except for you providing additional oxygenation and reassurance, the body will continue until it fatiques or definitive treatment is provided. 

Watching the way someone breathes, quality, rate and depth can provide many clues to what is going on within the body to compliment the rest of your assessment.

Oops, sorry BossyCow, didn't mean to post what you had already said.


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## Gbro (Oct 15, 2007)

Very informative post Vent, But I confess I don't understand a lot of it. I kept getting the idea you were talking about a Unconscious Pt. as anxiety levels on most pt's greatly influence how they breath.

OK here is what i did for this Pt. as he was greatly agitated, Stating "WHAT IS HAPPENING TO ME"!!!. That was the overriding response i got from him.

His R-rate was 32+ congested wet sounding w/accessory mussels.
I held his hand and monitored pulse and coached him to *"breath in through his mouth and out through his nose".* This didn't happen immediately, as he would gasp and cry out with above statement. But upon talking him through the sequence for about a min, he started to get the pattern down and his breathing started to slow. 
The Rig was there in aprox. 4 min. and O-2 started. Saturation was 92%
Baby aspirin was administered, B/P was 160/?? and although he had taken 2 nitro prior to 911 call with no relief, his chest pain was an 8. Sub-lingual nitro was administered. Upon setting up to transfer pt. to the cot he states that he feels fine now and doesn't want to go in.(he had been transported 1 week prior). This Pt had to go in, He is just temporary stabilized. We can't treat and leave. But this man is adamant, He wants to stay home.
After some discussion about how he felt before calling 911 and that he will probably repeat that shortly after we leave, he somewhat relented and was transported.


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## VentMedic (Oct 15, 2007)

No Gbro. I was only writing of the conscious patient.  Once they go unconscious then I may HAVE to take over the breathing.  If they are still conscious and mentating I will do what I can to take away some of the anxiety factor but I also know their body is struggling to compensate for something that is not functioning well.  

There are some very effective techniques that can be taught if the problem is purely oxygenation or ventilation to "PEEP" and splint the airways. Mixed problems that also involve acid-base or cardiac output abnormalities can be more difficult. 

I only explained some of the physicological basics as to why a patient breathes rapid and appears anxious.  As in the case of your patient, his body is now in a survival mode and his breathing is being controlled by some of the various receptors you may have heard about briefly either in EMT school or on this forum.  

Denial and the feeling of a lack of control over what is happening to them is part of the disease process especially in cardiac situations.  The lack of control is not only from EMS people telling him he needs to go to the hospital but also the many changes he body is experiencing to stay alive. His breathing is now a fight for survival and nobody is going to tell the body any different until it wears out.  Supportive measures and treatment as you described to provide relief can give the body a break to "catch its breath".


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## Gbro (Oct 15, 2007)

I was told about this technique after a very bad asthmatic run, one of the RT's said this "in through the mouth and out through the nose" dose several things, Just the boring coaching helps lessen the anxiety, and the use of alternate air passages helps with getting more O-2 into the lungs, and the restriction of exhaling through the nose helps by creating some back pressure in the lungs that i was told expands them and helps resist pulmonary edema.
This RT is a wonderful person who worked tirelessly with one of my Grandchildren that was born 9 weeks Preemie, and had many episodes of respirations exceeding 60 breaths per min.(RSV)?


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## VentMedic (Oct 15, 2007)

That is correct for some patients. Pursed lip breathing works for some also. Once you know the basic physiology of what the body needs you can then support and/or coach them appropriately. 

The nose has receptor sites also. The body also responds differently when it senses the mouth is open. The body believes it is losing CO2 and will slow it respiratory rate. This is now being studied in sleep labs throughout the world now as another cause to sleep apea(sorry off subject). So there is a scientific basis for breathing techniques. Again, one has to look at the goals of the body.

The back pressure you mentioned is the PEEP effect I mentioned in the previous post.

Keep in touch with that RT. She can be a good resource.


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## Gbro (Oct 16, 2007)

That is the problem, as She is now into the sleep disorder field. I am sure she is doing wonderful things in that field.
So there is merit in coaching respirations. We just have to know when and where.
At a recent 1st responder training session where i work my 40+ hrs. I had the new members, while hooked to the pulse OX, without increasing there rate breath in through the mouth and out through ....... and watch the reading on their O-2 saturation. There was an increase in the reading within 30 sec.. Granted deep breathing will also give those results. 

Thank you Vent-Medic for the info.
Could we now discuss different kinds like the pursed lip breathing. 
If I remember right, that one is for the CHF's?


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## VentMedic (Oct 16, 2007)

*Pursed lip breathing* is often taught to COPD patients. It could be effective in patients experiencing other oxygenation problem. 

The patient inhales deeply through the nose ("smell the flowers") and exhale through pursed lips ("blow out the candle"). If the patient can't purse his lips, teach him to exhale through a drinking straw or through a fist placed against his mouth.  I prefer the patient to be exhaling against the mouthpiece of the medication nebulizer (face mask nebs not as effective).  They will be exhaling through a smaller orifice and against a small flow. 

*paced diaphragmatic, or abdominal, breathing*, the patient actively uses his diaphragm. Because this type of breathing requires more energy than pursed-lips breathing, it is taught when the patient *isn't experiencing severe dyspnea. *

The patient place one hand flat against his body below the bottom of the sternum and above the waist with the other hand about an inch (2 to 3 cm) below the first hand. Instruct him to breathe in through the nose. Encourage him to concentrate on expanding his diaphragm while he breathes in. He'll be able to feel his lower hand move up as the diaphragm expands. (The upper hand shouldn't move.) When he exhales through the mouth using the pursed-lips technique, his lower hand should move down as his diaphragm rises. 

Babies grunt (push against a closed glottis) to open the air sacs in the lungs periodically. This is the baby equivalent of a sigh or "pursed lip" breathing. You may hear a healthy baby do this while they are sleeping. During quiet, shallow respiration, many of the alveoli in the lung collapse due to the normal surface tension in the lungs.  If there is a disease process closing the alveoli, you will hear the babies grunt with almost each breath.  You may also see children place their arms above their heads when they are having difficulty breathing. 

*Anxiety "hyperventilation*" - true hyperventilaton syndrome is diagnosed with a blood gas. 

For problems such as DKA, hyperventilation it is welcomed as compensation until definitive treatment. Understanding the patient needs to breathe rapidly to maintain a blood pH compatible with life, you can get the patient to concentrate on quick deep rhythmic breaths which the body may be trying to do all ready. Their concentration on effective breathing will hopefully reduce the anxiety that they are feeling during DKA with the different chemical changes including those concerning the respiratory system.

Hypoxia can also be a cause of anxiety *and* hyperventilation even with SpO2 of 100%. They may be using their increased ventilation to maintain oxygenation. Respiratory alkalosis from overbreathing which "blows off" CO2 leads to shifts of calcium ions in the blood which induces nerve tetany and carpopedal spasm. The patient feels the tingling and numb sensations. Slowing the respirations will restore CO2 balance will ease these effects, but if the patient is truly hypoxic for some as yet undiscovered reason (and this is masked by the overbreathing), the oxygen will relieve that.  Supplemental O2 is okay if you want to start at 2 L/NC. You may have to adjust if it is a true oxygenation problem. It may calm the patient by feeling you are doing something other than just saying "calm down" and "breathe correctly". 

Some of this may go against your local protocols such as providing O2. But, assessment, common sense and education/knowledge would hopefully prevail is some situations.


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## Gbro (Oct 16, 2007)

> The patient inhales deeply through the nose ("smell the flowers") and exhale through pursed lips ("blow out the candle").



Having poor nasal passages, i have a hard time myself breathing in through my nose, I couldn't imagine having someone coach me through this if I was anxious. 
I remember my 1st time at 10,000 ft. I was walking while eating an apple. I couldn't do it. i had to stop and mouth breath for awhile.
So is the in through mouth, out through nose even used in your field?

Again thank you for your posts.


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## DisasterMedTech (Oct 16, 2007)

I think get a resp rate on him, get a pulse. Then just start talking to him, asking him questions, gently assuring him that he will be alright, help is on the way. I always try to ask them to "slow down your breathing for me if you can....you'll feel better."  There's always the old paper bag trick, which of course has no actual physiological value but works a great part of the time anyway.


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## VentMedic (Oct 17, 2007)

DisasterMedTech said:


> There's always the old paper bag trick, which of course has *no actual physiological value *but works a great part of the time anyway.



1.  Raises CO2

2.  Decreases pH which can further compromise an acidotic metabolic situation

3.  Dilates blood vessels in the head

4.  Can lead to more hypoxia

5.  Can promote a reactive airway reaction with dust particles.

If you can get the patient to calm down enough to stick their face in a paper bag, there should be another alternative.

I would be cautious using the paper bag.


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## BossyCow (Oct 17, 2007)

VentMedic said:


> .....If you can get the patient to calm down enough to stick their face in a paper bag, there should be another alternative.





Now that's funny! I had a pt that when presented with the paper bag to help her hyperventilation promptly puked into it.


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## Gbro (Oct 17, 2007)

Instead of the paper bag, Some use a non-rebreather and stop the 0-2 flow while closely monitoring pt.
This is refered to as "Zebra 0-2", (the pt. isn't aware of what you are doing).
At least that is what i have been told.


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## Paramajik (Oct 18, 2007)

A NRB or partial NRB w/ 2-3 l/m oxygen attached works well for psychogenic hyperventilation.  One also might try 20-30" of ventilator tubing as well.  Just have the patient breath through it.  You just might consider placing NC oxygen as well.  Just in case there is a hypoxic component...

VentMedic... awesome overview! Thanks!!


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## ffemt8978 (Oct 18, 2007)

We're specifically prevented, by protocols, from using the paper bag method.  Our MPD has some serious concerns based upon the very points that VentMedic listed.


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## DisasterMedTech (Oct 18, 2007)

VentMedic said:


> 1.  Raises CO2
> 
> 2.  Decreases pH which can further compromise an acidotic metabolic situation
> 
> ...




Thats great to know. We were taught in EMT school that its just psycho-somatic with no true altering of physiology. Its times like these that I am glad we have RTs around. Thanks for the advice.


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