1 Respiratory Assessment and Initial Priorities

How breathing and gas exchange work

The respiratory system moves air to the lungs and exchanges gases with the blood. The Upper airway—nose, mouth, pharynx, and larynx—conducts air toward the Lower airway, which includes the trachea, bronchi, and smaller bronchioles. The bronchioles end in alveoli, tiny air sacs surrounded by capillaries. Oxygen moves from the alveoli into the blood, while carbon dioxide moves from the blood into the alveoli to be exhaled.

Breathing depends on air moving through an open airway and the chest expanding and recoiling. The diaphragm and other respiratory muscles create pressure changes that draw air in and push it out. Ventilation is the movement of air in and out of the lungs; Oxygenation is the transfer of oxygen into the blood. A person can have a problem with either process or both. Supplemental oxygen can increase the oxygen available for breathing, but it does not by itself correct inadequate ventilation or an obstructed airway.

Start with safety and a rapid check

Begin with scene safety and personal protective equipment. Quickly assess whether the person is responsive and whether breathing is present and normal. If the person appears seriously ill or injured, activate the emergency response system; do not delay urgent care to complete a detailed examination.

Reassess the person as needed. Look at breathing, air movement, appearance, and mental status together rather than relying on a single observation or device reading.

Conduct a focused respiratory assessment

Assess the following features and watch for changes:

• Rate and pattern: Determine whether breathing is unusually fast, slow, shallow, irregular, gasping, or absent. Count breaths when possible; a changing rate or pattern may signal deterioration.

• Work of breathing: Look for accessory-muscle use, nasal flaring, retractions between or below the ribs, inability to speak in full sentences, or a hunched posture.

• Air movement and sounds: Listen for noisy or obstructed breathing, wheezing, or unusually weak or absent breath sounds. Note whether the chest rises evenly.

• Appearance and mental status: Watch for pale, gray, or bluish skin, sweating, agitation, confusion, drowsiness, or reduced responsiveness.

• Oxygen saturation, if available: Treat the reading as one piece of information, not a substitute for observing the person. A pulse oximeter can miss low oxygen levels, and readings can be affected by patient, device, and environmental factors.

• Brief history: Ask what happened, when symptoms began, and about relevant conditions, medications, allergies, and possible choking, smoke, or chemical exposure—if asking does not delay emergency action.

Recognize distress and worsening breathing

Respiratory distress means breathing is difficult or requires increased effort. Signs include rapid breathing, accessory-muscle use, retractions, restlessness, sweating, and trouble speaking. Distress can progress to respiratory failure, when breathing no longer adequately supports oxygenation, carbon-dioxide removal, or both.

A particularly dangerous change is a person who becomes quieter, more tired, less responsive, or breathes more slowly or shallowly after struggling. Decreasing effort is not necessarily improvement; it may indicate fatigue and impending respiratory arrest. Cyanosis may occur, but it is not a reliable early warning sign.

Prioritize support and emergency response

1. Protect yourself and summon help. Make the scene safe, use appropriate protective equipment, and activate EMS for severe or worsening breathing problems.

2. Support a comfortable position. If the person is awake, let them sit upright or adopt the position that makes breathing easiest. Avoid unnecessary movement.

3. Check and support the airway. Look for an obvious obstruction. If the person is unresponsive, use an airway-opening maneuver appropriate to your training and the situation. Do not perform a blind finger sweep. Suction or advanced airway interventions should be performed only by trained responders using appropriate equipment.

4. Assess breathing and respond to what you find. For a person who is breathing but distressed, continue monitoring and follow your training and local protocols. Oxygen is not a substitute for effective breaths. If breathing is absent or inadequate, a trained responder should provide rescue breathing or bag-mask ventilation as indicated by current training and protocols.

5. Respond to unresponsiveness with abnormal breathing. If the person is unresponsive and not breathing normally, activate EMS, obtain an AED, and start CPR or rescue breathing according to your training and the applicable algorithm. Continue reassessing until help takes over.