Difficulty Breathing—Control, Or Not?

Question: We received a call from a first-party caller who was home alone. He was having difficulty breathing and in severe distress. The Emergency Dispatcher correctly chose Protocol 6 [Breathing Problems]. To calm the patient's breathing, the Emergency Dispatcher instructed the patient to “take deep breaths.” I have seen in previous postings that Emergency Dispatchers should not instruct patients who are in respiratory distress to take deep breaths. Are there any articles available that discuss this? The only one I found dealt with an anxiety attack. 
Debbie Pando 
Ocala, Florida (USA) 

Hi Debbie, 
Thank you for your question. To be clear, we do not want to advise any specific method of breathing to patients with breathing difficulties (i.e., deep breathing, rapid breathing, breathing into a paper bag, etc.) in the protocol or through ad-lib enhancement in any way, shape, or form. (Click to see the CBS “60 Minutes” Lam case—Los Angeles, California (USA), 1987). 

The only exception to this statement exists in Protocol 24: Childbirth PAIs F-12, F-25, and F-27, which is not advice dealing with breathing problems, but in aiding breathing as an adjunct to the childbirth delivery process. 

There are many causes of difficulty breathing. Generally, it is caused by acute or chronic lung problems like asthma, COPD, pulmonary emboli (blood clots), or pulmonary edema. However, there are many other root causes. Uncontrolled diabetes can elevate a patient's breathing rate, and this may cause the patient to complain of a breathing problem. This is why we ask if the patient is breathing normally on Protocol 13: Diabetic Problems. Many heart problems, including heart failure or heart rate and rhythm problems, can present with difficulty breathing. 

Protocol 6 Axiom 1 says, “While true hyperventilation is a benign (not serious) condition, EMDs should never assume it exists. Advising breathing into a paper bag is considered to be EMD malpractice.” This Axiom, which was developed through actual case precedence, clearly informs us of the risks associated with “dispatcher diagnosis” and providing instructions not included in the protocol. Instructions to change or slow a patient's respiratory rate—the exception being the protocol-scripted deep breathing instructions included in the childbirth sequence (as mentioned above)—should never be advised. 

The relatively common complaint of “anxiety attack,” which is not a true diagnosis but rather a symptom of many other mental health conditions or other less typical causes like physical uneasiness, pain, nausea, acrophobia, or claustrophobia, should never be accepted at face value. More appropriately, the EMD should find out exactly what happened and, if rapid breathing is the complaint, use Protocol 6. Anxiety disorder as a cause of breathing problems should only be diagnosed by a clinician after carefully ruling out other potential causes. However, these distinctions should never be made by the caller, patient, or EMD at the point of dispatch. 

Regardless of the cause, when a person complains of difficulty breathing—typically faster and more laborious than normal—the body reacts to what is happening at the cellular level, which is usually insufficient oxygen delivery to the tissues or, more rarely, an indirect metabolic disorder such as high blood sugar. Regardless, these patients are breathing at the body's self-adjusting, compensatory rate, and any attempt to change the rate could have dire consequences. 

If the EMD happens to use deep, slow breathing as a “calming” or caller management statement for patients with breathing difficulty, we need to work with them to add more appropriate “tools to their toolbox.” Being prepared with plenty of appropriate calming statements makes the Emergency Dispatcher more effective and confident in mitigating caller emotion without adversely affecting the patient’s clinical condition.