Respiratory distress

Voiceover:Respiratory distress is one of those things where if you had it, nobody has to tell you that you're short of breath. But I think it's important to recognize when somebody else is in respiratory distress. First, let's just draw our generic patient. Let's call him Bob and let's give him some hair. I feel like giving hair to my stick figures masks the fact that I can't draw (laughs). Okay, so Bob here has respiratory distress. Let's draw the rest of his body. Here we're gonna talk about acute respiratory distress. In other words, it happened pretty recently in terms of days not like Bob has had lung disease for years and years. That will look like a different picture. If somebody has respiratory distress, we're going to talk about the things you can see to tell you and things you can hear. Those are the only two senses that are really important. I don't think you can touch or taste respiratory distress. In terms of things you can see. First of all, you never really see a person lying down saying, "I'm short of breath." The first thing that somebody would do if they're short of breath is to sit up. That's why in the hospital if somebody has lung disease you rarely see them lying down all the way in bed. Now, of course, there are many different kinds of lung disease, but the fact that they like to sit up has a few common reasons. First there's our muscle called the diaphragm. In normal breathing this curved muscle moves down, which expands the chest cavity and that's how air goes in through your mouth and your nose. Just by simple rule of gravity we have to move something down and it's easier to do that when sitting up. Just so you don't have to fight the push of gravity down on your chest where you're trying to move your diaphragm toward your feet. Another reason, the reason you are short of breath is because a fluid, if we think about how fluid behaves then when it's flat, again, gravity makes it distribute all over the place and your whole lungs are bathed in the fluid. If you sit up the fluid kind of pulls to the bottom. This frees up the top of the lungs here to breathe a little better, so usually people like to sit up when they can't breathe. Next, you might notice that the rate of breathing might go up. In an adult, our normal rate of breathing is eight to 16 per minute and this is gonna go up just because when you can't move breath as well people tend to compensate by breathing more. Along with that, the panic of breathing faster and everything, happens to trigger the sympathetic nervous system, which is our fight or flight response. This is what happens to your body when it's in an emergency and it's trying to either run away or fight. One thing that happens here, which is kind of not related to our topic is that sympathetic nervous system allows your pupils to get bigger. This allows more light in and additionally your blood flows to your arms and your legs and away from your intestines so you don't have to digest for the few minutes that you're gonna be fighting. In our lungs, though, sympathetic nervous system can cause bronchial dilation, which literally just means these airways in our lungs as they branch off, they get bigger. And just the bigger diameter allows air to flow better. I didn't mean to draw his trachea, his windpipe, so deviated here. Imagine that this is straight down and in the middle of the neck. But in fact, actually if you have respiratory distress because of something like a pneumal thorax, when one lung has collapsed, then this trachea would deviate to one side or the other. But we can't see that by just looking at the person without an x-ray or some other form of imaging. Today we're just talking about naked eye seeing someone. So rate goes up and then the next thing there's a group of signs we call it increased work of breathing. Which is at the same time really specific, work of breathing, and also really vague, what is that? Work of breathing usually is pretty quiet. The diaphragm moves down, the chest expands as you're doing right now it doesn't take too much conscious effort. If someone is short of breath, other muscles get recruited. Like muscles in the neck, muscles in the shoulders. You might see them kind of tensing up their neck and shoulders trying to force that chest cavity bigger. Additionally, we have these what's called retractions, which just means there's muscles between our ribs. Our ribs going all the way up and the muscles between them can work so hard to compensate for respiratory distress that you can see the markings. If you take off our patient's shirt, you might be able to see the traces of their ribs both because the muscles are working hard and the decreased pressure in the lungs because you can't breathe well sucks that tissue in. These tracks are called retractions and that's part of work of breathing. In an infant, you might see something called nasal flaring, where their nostrils get bigger. If you try it right now you can sort of consciously increase the size of your nostrils and that just, again, let's more air in. That's more seen in little babies. Another thing you might see is called cyanosis. Which it just means that it's blue, purplish discoloration. Now, we think of blue blood as being lacking oxygen and it's not really blue, but it's just a little darker. This in our body can show up kind of bluish. This actually tends to happen in mucous membranes because there's less skin to cover that color. So in the lips and in the eyes and sometimes in the extremities just because they're the furthest away from our heart. So the hands and the feet sometimes might get blue. Now we're talking about acute distress here, but if Bob goes on to have this for years and years, a sign you can see in chronic respiratory distress is called clubbing. Usually we have our hand, 1,2,3 that's 4 fingers. So you have your hand and the fingers kind of taper off at the fingertips, that's the normal shape. But in clubbing, the tips of the fingers get big and kind of sausage like instead of tapering. It's called clubbing and this is chronic. The theory is that because these tips lack oxygen year in, year out, they kind of go through this hypertrophuge, which means more tissues grow to try to gather more oxygen. That's why clubbing happens. This again, is chronic. So now you can see it today in Bob since he just developed this. Alright, now moving on to things you can hear. There are a lot of lung sounds that are associated with having lung disease, but in terms of respiratory distress one thing that comes to mind is stridor. Stridor is usually above the chest cavity so the restriction is not so much down there but up here in the shoulder and neck level. I don't know if I can make a convincing noise for stridor, but it just sounds like (labored inhale). When this person is taking a breath in there's that extra noise. It's like if you put a straw in your mouth and you try to inhale, this is an inhalation noise. Next, you might hear some grunting. This is just because there are so many muscles between the abs, the shoulders, the neck trying to force air in and out and some of it goes across our vocal cords. And it just makes a grunt. This is like in the movies in the martial arts when they're punching someone and just using so much muscle force that this grunt escapes. In general I think of grunting as kind of an exhaling noise. For example, in emphysema when air doesn't get out some patients use their abs to try to force it out. And the grunting happens when they exhale. Usually an adult should be able to say, "I can't breathe." They might not say respiratory distress, but they will definitely say, "I can't catch my breath." But in the event that they can't tell you that or if it's a baby or a child, it's important to keep these signs in mind. The things you can see and you can hear when somebody's in respiratory distress.