Prevent and prepare

• Be aware of any conditions, such as asthma or lung disease, that family, friends, and co-workers have; and how to help them if there is an emergency.
• If possible, avoid entering places with poisonous gases or smoke without appropriate breathing equipment.

Early recognition

Breathing difficulties can be subjective. What may seem severe to one person may not be severe to another. Listen to the person and look for clues in their behaviour and the surrounding environment.

The person may tell you or indicate that they are having difficulty breathing, or that they have a pre-existing medical condition such as asthma  or lung disease.

The signs and symptoms a first aid provider may look for to indicate breathing difficulties include:

• shortness of breath
• laboured breathing
• noisy breathing
• coughing
• rapid breathing rate (more than 40 breaths per minute in babies; 30 in children; 20 in adults)
• slow breathing rate (less than 25 breaths per minute in babies; 15 in children; 10 in adults)
• not being able to count to 10 after one deep breath in
• use of accessory muscles for breathing (neck, shoulders)
• movement of nostrils
• bluish colour to the skin of the lips, ears, fingers and toes.

Hyperventilation is also characterised by other typical signs and symptoms, such as:

• dizziness
• headache
• sweating
• tingling sensation in hands, feet, fingers or mouth.

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NOTE

Be alert as dangerous gases and other substances can cause breathing difficulties.

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First aid steps

Breathing difficulties

1. Help the person into a comfortable (usually seated) position and reassure them. They may experience relief by sitting leaning forward with arms braced and leaning on a support.
2. Assist them to take their medication if they have any. Loosen any tight clothing.
3. Access EMS immediately if:

>   their medication is ineffective after a couple of minutes
>   the person is experiencing severe breathing difficulties
>   the person has a change in mental status, such as confusion, drowsiness or unresponsiveness
>   their breathing becomes slow
>   their lips, fingers or ears turn a bluish colour.

4.  If properly trained and access to supplementary oxygen is available, give it to the person as needed. (See Oxygen administration.)
5.  Continue to observe the person, keeping them calm and comfortable. Stay with the person until their breathing returns to normal.

Hyperventilating

If the person is hyperventilating:

1. Move the person to a quiet place and ask bystanders to keep their distance. If possible, remove the cause of the panic attack.
2. Comfort the person and act calmly and predictably. Ask them to breathe in and out slowly and steadily into their shell-folded, closed hands or into a paper bag.
3. Loosen any tight clothing.
4. Stay with the person until their breathing returns to normal. Once calmed down, let them breathe in ambient air.

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NOTE

If the person is unresponsive, open their airway and check for breathing. See Unresponsiveness.

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Access help

• In the case of hyperventilation, access EMS if:
  >    the panic attack continues
  >    you suspect that it may not be caused by a panic attack.

Recovery

• Following a person’s first episode of breathing difficulties, encourage them to start to recognise the signs of breathing difficulties as early as possible. This is so they can consider taking their medication (if they have any) and to get into the most comfortable position possible or access help if signs are severe.
• Encourage the person to seek specialised medical care for recurring panic attacks.

Context considerations

• Research has identified that both within and between communities, people may treat breathing difficulties differently. Some communities and individuals wait to seek assistance when in a much more advanced phase of illness (Cartledge et al., 2017).
• In remote areas, it may be beneficial to drive towards the nearest medical facility and meet the EMS vehicle en-route. First aid programme designers should know the availability and response time of pre-hospital services in their area as these may be limited. Education should emphasise that early recognition of potentially time-critical problems is essential.
• Tailor education to learner needs according to the environment they are in (for example areas of high air pollution); or if there is a particular situation where breathing difficulties might become apparent (such as during a Pandemic).
• Non-emergency medical services may be able to treat breathing difficulties that occur slowly and over time. First aid education should include advice about the available options in local health services.

Learner considerations

• Educators should be mindful of the cultural, gender and age-based factors that may influence learners’ understanding of breathing difficulties and severity. Ensure first aid programme content is inclusive.
• Learning about how to recognise and respond to breathing difficulties could benefit carers of older adults who have chronic lung or heart conditions, parents with babies, and caregivers of children with asthma.
• Learners who spend time in smoky or dusty environments (such as firefighters or construction workers), or in places where there might be chemicals (such as laboratories, factories or farms), could benefit from learning about breathing difficulties.

Facilitation tips

• Emphasise the importance of listening to the person’s breathing to help identify any problems that may worsen and result in a medical emergency. Highlight that breathing can deteriorate over time.
• Re-visit what “normal” breathing looks like by counting breathing rates and regularity.
• Ask learners to show how they think someone may look or act when experiencing breathing difficulties.
• Explore learners’ understanding of the term “breathing difficulty”, as well as the causes and their experience with it. They might have different interpretations which could affect their response and willingness to act. For example, people with a specific type of breathing difficulty called orthopnoea have trouble breathing when they lie down, typically at night, and may not seek assistance if they feel they can resolve the symptom by sitting upright.
• Run scenarios to rehearse recognising and responding to the typical presentation of various types of breathing difficulties. Assessing the scene for hazards should be a part of the exercise.
• Regarding hyperventilation, explain the purpose of breathing into shell-folded, closed hands or into a paper bag is to develop a normal balance between the amount of oxygen and carbon dioxide in the blood.
• Explain to learners that someone who is hyperventilating may benefit from following a breathing rhythm. Have learners practise setting an example and encouraging someone to follow their breathing rhythm. This may have a count of one to breathe in through the nose and a count of three to breathe out through the mouth.

Facilitator tools

• Use videos to show normal breathing and changes in breathing (e.g., asthma attack), as well as brief clips to demonstrate life-threatening breathing problems.
• Use scenario-based learning to help individuals integrate assessment skills. (See General approach.)
• A method of assessing breathing difficulty is to ask the person to take a deep breath and then have them count from 1 to 30, clearly but quickly (Roth Score). If the person cannot count to 10, at most, they have breathing difficulties. Give learners time to practise this method.

Learning connections

• Common causes of breathing difficulties include Chest injury, chronic obstructive lung disease, bronchitis, Croup (babies and children) and bronchiolitis (babies and young children).
• Other life-threatening conditions which result in breathing difficulty include Choking, heart failure (see Unresponsive and abnormal breathing) and Asthma attack.
• Consider whether it is appropriate for learners to learn about Use of oxygen.
• Any stressful situation, including ones where first aid for injuries and illness might be required, could cause some people to panic. (See Traumatic event.) Learning how to calm a person who is hyperventilating could be an important part of scene management.