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Tripod position - respiratory distress

Respiratory distress is when your body needs more oxygen (such as after running an intense race). It’s fairly easy to spot with some clues in mind:

  • Rapid breathing (tachypnea): More breaths (up to 40-50 breaths/minute) means more oxygen is brought into the body over a period of time.
  • Deep breathing: Deep breaths allows each breath takes in more oxygen.
  • Tripod position: A person will subconsciously place their hands on their knees and lean forward to use the "strap" muscles of the neck. This position provides a mechanical advantage, making it easier to sucking more air in!

 

These signs may not be a problem if you're physically exerting yourself, but if you see these signs in a person who is at rest, then there may be an illness brewing. Check out our video on inhaling and exhaling to refresh your memory on the basics of breathing.

Some other clues to detect respiratory distress could be:

Preferred resting positions: Orthopnea is the feeling of being short of breath when lying flat on your back (e.g. sleeping). Often times, patients will prop themselves up in bed with pillows to help them breathe easier.

Orthopnea - respiratory distress

People with chronic heart or lung problems often have orthopnea because they have excess fluid in their lungs, which pools when a person lies flat. The fluid limits gas exchange and leads to the feeling of shortness of breath (dyspnea).

Listen to them speak: Have you ever seen a news reporter interview an athlete just after they’ve competed in an event? The athlete is usually out of breath if their sport required them to physically exert themselves. Pay attention to whether the athlete needs to take a breathe mid-sentence while they is speak. Running out of breath while speaking is typical during physical exertion, but is very unusual while at rest and could be a sign of respiratory distress.

Look for a change in colour: Have you ever heard you’d turn blue if you held your breath? That’s not completely true however, low levels of oxygen in your blood (a condition called hypoxemia) can cause your hands/feet to turn a bluish-purple color - a symptom called cyanosis. Cyanosis can look really different depending on someone’s skin tone. People with light-colored skin can have a bluish hue in the nail beds, palms/soles, lips, and earlobes, whereas people with dark-colored skin might have a grey or ash colour in their nail beds. While you're looking at the nails, also look for clubbing which is when the fingernails spoon over the tips of the fingers and the finger tips start looking like a little club or chicken drumstick.

Cyanosis - respiratory distress

Watch for seesaw-like abdominal breathing: Imagine looking at someone lying on their back from the side. When they breathe in, their chest and abdomen rise upwards together, and when they breath out their chest and abdomen descend together. Paradoxical breathing is when the chest and abdomen are moving opposite of each other. In inspiration, the chest will rise but the abdomen will fall, and in expiration the chest will fall and the abdomen will rise.

Paradoxical breathing - respiratory distress

Paradoxical breathing occurs when part of the chest wall is broken and has become flexible. During inspiration the chest moves upwards reducing the pressure within the thorax, but because the chest wall is no longer sturdy, it gets sucked into the chest cavity. Similarly when the chest falls during expiration, thoracic pressure increases and the malleable chest wall is pushed outwards. Paradoxical breathing is seen in patients with chest trauma, often from motor vehicle accidents.

Look for indrawing of the chest wall: Pretend you have a soda bottle with a balloon on the inside. The end of the balloon is open to the outside air (as shown in the animation below). You’ve sawed off the end of the bottle and covered it with a big rubber sheet. Let’s imagine the soda bottle is your chest wall, the balloon is your lungs and respiratory tract, and the green rubber sheet is your diaphragm. If you pull on the rubber sheet, you create a low pressure inside the bottle by increasing the volume of the bottle. Air from outside the bottle rushes into the balloon to equalizes the pressure. This is how inhalation works! Your diaphragm increases the chest cavity size, and air rushes into your lungs to equalize the pressure by expanding your lungs.

Breathing analogy - respiratory distress

If you let go of the rubber sheet, the volume of the bottle decreases. This creates a high pressure in the chest cavity. Air will rush out of the balloon to once again equalize the pressure. This is how expiration works. Your diaphragm relaxes, your chest cavity shrinks, and the air in your lungs gets pushed out.

What if there was an obstruction in the neck of the balloon? When we pull on the rubber sheet and decrease pressure in the bottle, little to no air can rush in! The pressure in the bottle would continue to be low and eventually may become so low the wall of the bottle might start to collapse inwards. The collapsing of the bottle’s walls is what retractions are in a patient’s chest wall. The pressure in the chest cavity gets so low that the soft tissue of the chest wall gets pulled in!

Retractions analogy - respiratory distress

Retractions are are classified by their location.

  • Subcostal retractions: Indrawing of the abdomen just below the rib cage (sometimes referred to as belly breathing).
  • Substernal retractions: Indrawing of the abdomen just below the sternum (breastbone).
  • Intercostal retractions: Indrawing of the skin in between each rib
  • Suprasternal retractions (tracheal tug): Indrawing of the skin in the middle of the neck above the sternum (breastbone).

Retraction location - respiratory distress

Supraclavicular retractions: Indrawing of the skin of the neck above the collarbone.

Fun fact! The location of a patient’s retractions can roughly tell you where an obstruction is in the respiratory tract. If the obstruction is in the upper airways, suprasternal and supraclavicular retractions will be visible. If the obstruction is in the lower airways, subcostal and substernal retractions will be visible.

Retractions are usually seen in infants and children (because their chests are more malleable than adults) with conditions like bronchiolitis and croup, but patients with asthma, anaphylaxis, pneumonia, or epiglottitis can have retractions at any age. Seeing retractions on a patient is usually serious. Retractions indicate the patient is working very hard to breath and soon maybe become too tired to continue breathing!

Listen for high-pitched sounds: Patients with restricted airflow to the lungs sometimes make a high-pitched sound called stridor. The sound is caused by turbulent airflow in the respiratory tract (similar to a bruit in blood vessels) and caused by the narrowing of air passages due to inflamed of the respiratory tissues. Hearing stridor is a big red flag a patient is in respiratory distress or may soon lose their airway.

Watch for rock stars: Head bobbing is caused when the scalene and sternocleidomastoid muscles contract to help a patient take bigger breaths. It’s only visible in infants because their neck extensor muscles have not developed enough to keep the head stable. Seeing a child head bob is an indicator the patient is in serious respiratory distress. Here's a video of a patient head bobbing.

Watch the nose: Look at your nostrils in the mirror and take a big deep breath. Did you see them widen slightly? That’s what nasal flaring looks like. Flaring of the nares with every breath is a sign of respiratory distress, and is most commonly seen in infants and young children.