Medical Patient Assessment for Respiratory Distress (PASTE)

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Part of	NREMT Skillset

Medical skill data
Subskill of	Medical Patient Assessment
Subskills	Alertness and Orientation Assessment (A&O) Alertness Assessment (AVPU) Bag Valve Mask Ventilation Cardiopulmonary Resuscitation (CPR) Respiratory Rate Assessment Airway Opening with Head Tilt and Chin Lift Non-Rebreather Mask O2 Administration Oxygen Administration Scene Assessment Upon Arrival (PENMAN) Carotid Pulse Palpation SAMPLE History Taking

Self-assessment
Use the PASTE acronym and practice asking the relevant questions and performing the focused physical exam until comfortable with the work flow Test your knowledge with this quiz

Annotations:

• 0:05 Scene Assessment Upon Arrival (PENMAN)
• 0:10 Alertness and Orientation Assessment (A&O)
• 0:19 Oxygen Administration
• 0:50 Lung Sound Auscultation
• 1:04 Non-Rebreather Mask O2 Administration
• 1:20 Vital Signs Assessment
• 1:21 SAMPLE History Taking

Dyspnea, the sensation of breathlessness and the patient's reaction to it, is often described by patients as difficulty breathing or chest tightness. Anything that can impair oxygenation and/or ventilation can cause dyspnea. Origins can involve many body systems, such as pathology affecting the lungs and airway, cardiovascular/hematologic dysfunction, and infection. Narrowing the differential diagnosis in the prehospital setting is important.

Having a structured and systematic approach to these cases will help you develop and streamline the diagnostic workup and more quickly determine transport priority. Severe dyspnea is a potentially life threatening situation which can deteriorate rapidly. You should not hesitate to start high flow oxygen therapy during your primary assessment.

Signs and Symptoms

Once immediate threats to life have been addressed, focus in on the underlying causes and potential treatments for a patient in respiratory distress. Use the PASTE mnemonic during the Signs and Symptoms step of the SAMPLE history to elicit the characteristics of the patient's dyspnea to help with the differential diagnosis.

PASTE Mnemonic for Respiratory Distress

Mnemonic component	Questions to Ask	Findings
Provocation and Progression	"What were you doing when it started? How long has this been going on? How has is changed over time?"	Find out whether any things such as movement or environmental factors are making the situation better or worse. This is especially important for toxic inhalation and allergic reactions.
Associated Chest Pain	"Is there any pain when you breathe?" Ask for a description of the nature and quality	Pain with breathing should increase your level of suspicion that the patient may be having a cardiac event or a pulmonary embolism. Add in the OPQRST mnemonic to your history taking.
Sputum (color and amount) /Speech	"Is anything coming up when you cough?" Ask for a description	Thick mucus that is yellow or greenish can indicate a respiratory infection, pink/frothy sputum indicates a potential cardiac origin.
Talking, Tiredness	Is the patient talking with you? Can they speak in complete sentences? Are they feeling tired?	Note if the patient can only speak in 1-2 word sentences.
Exercise Tolerance	"Could you walk across the room?"	It is important to monitor whether the condition of the patient is worsening with time.

Focused Physical Exam

Obtaining breath sounds is an important step in assessing a patient in respiratory distress. Auscultate the breath sounds over the bare chest with the diphragm of the sthoscop in firm contact with the skin. Check the breath sounds on the right and left sides of the chest and on the patient's back between and below the scapulae. Note assymetry between the two lungs, or any changes in sounds between the apex and the base of the lungs.

Breath Sounds	Disease	Associated Signs and Symptoms
Wheezes	Asthma COPD Congestive Heart Failure Pneumonia Bronchitis Anaphylaxis	Dyspnea Productive cough Dependent edema/pink frothy sputum Fever, pleuritic chest pain Clear or white sputum Hives, swelling, stridor
Rhonchi	COPD Pneumonia Bronchitis	Productive Cough Fever, pleuritic chest pain Clear or white sputum
Crackles	CHF/pulmonary edema pneumonia	Dependent edema, pink frothy sputum Fever, pleuritic chest pain
Stridor	Croup Epiglottitis	Fever, barking cough Fever, sore throat, drooling
Decreased or absent breath sounds	Asthma COPD Pneumonia Hemothorax Pneumothorax Atelectasis	non productive cough, dyspnea Productive cough Fever, pleuritic chest pain Shock, respiratory distres Dyspnea, pleuritic chest pain Fever, decreased oxygen saturation

Documentation

Documentation of a patient with SOB should be included in the Patient Care Report (PCR) in the form:

• "Patient presented in tripod position on kitchen chair upon EMS approach. Patient is tachypneic at 36 breaths/minute with audible wheezes. Wheezes auscultated in all fields. Patient able to speak in 1-2 word sentences. Patient assessment shows sternal, intercostal, and subclavicular retractions. Patient has history of asthma attack and has had to be intubated previously. Patient denies cough or recent illness, no sputum production or associated chest pain noted. Patient's mother states that patient came back from a run stating that he felt like he was starting to have an asthma attack after running through a cloud of pollen on his way home. Patient has taken prescribed albuterol inhaler x2 to no relief."

Tips and Tricks

1. Some respiratory diseases such as asthma, COPD, and CHF are chronic. The patient will know they have a respiratory disease and will often have a fairly good idea of how the disease has progressed/felt in the past. Asking if this time feels better/worse than others is a good way of establishing a baseline.
2. Ask if a patient has a rescue inhaler, and if so have they taken it? If so, has the inhaler worked? Be sure to check the expiration of any patient medications of this sort, especially if the patient has not had an attack for some time. Many patients will keep old inhalers that may have reduced efficacy because they believe they do not need a new prescription.
3. Congestive heart failure by itself is a chronic cardiac condition, it is not a respiratory disease/emergency. Acute exacerbations of CHF lead to a rapid increase in pulmonary edema. This creates a V/Q mismatch; the inability of CO2 to offload and O2 to load onto hemoglobin is the cause of the hypoxia and respiratory distress found in CHF exacerbation.

Additional Resources

• Audible breath sound bits can be found here. Additional audio can be found here.

References

TBD - Footnotes, references, standards