Breathing Management of respiratory distress

The ability to assess a patient for respiratory distress and adequacy of ventilation is essential at all levels of the health care system. This applies both to those initially evaluating the patient and to those who are providing definitive care. The only resources required for this function are training and a stethoscope. If no other resources are available at the level in question, it is anticipated that respiratory distress would usually constitute grounds for referral to the next highest level of the system.

Capabilities for the administration of oxygen to trauma patients in respiratory distress are essential at all hospital facilities. This would be useful at all levels of the health system. It is recognized that this is currently beyond the realm of feasibility for most primary health care clinics with non-medical staff in low-income countries. However, facilities that receive a moderate volume of seriously injured patients (e.g. those located along busier roadways), especially in middle-income settings, might realistically be supplied with oxygen. The capability for administration of oxygen implies both health care providers capable of understanding the indications for its use and equipment and supplies to administer it in a timely fashion to trauma patients in respiratory distress. In most cases, this implies that the physical resources are present in the area where acute trauma patients are initially received. WHO's Department of Essential Health Technologies (EHT) is developing guidelines for the use of oxygen and related training and equipment (http://www.who.int/eht).

The recognition of tension pneumothorax, its primary treatment by needle thoracostomy and definitive treatment by tube thoracostomy are essential at all hospital-level facilities that handle trauma. This implies sufficient training of the principal caregiver in the diagnosis of tension pneumothorax and in the safe performance of the relevant procedures. It also implies the ready availability of the needed materials, including a basic trauma pack, chest tubes and underwater seal drainage bottles.

At the basic health care level, capabilities for the recognition of tension pneumothorax and temporary relief with a needle thoracostomy could be considered desirable in settings with the possibility of rapid evacuation to a site of definitive treatment. This would usually imply the existence of an EMS system.

Recognition of the presence of a sucking chest wound and the ability to apply a three-way dressing for immediate treatment is deemed essential at all levels.

Assessment of the adequacy of supplemental oxygen is based primarily on clinical examination. Supplemental laboratory measurements (arterial blood gas concentration) and monitoring (oxygen saturation through pulse oximetry) provide further useful information. However, their cost prevents them from being deemed essential for all environments. They are listed as desirable and might especially be considered in environments with better access to resources.

When ventilation is inadequate, it can be supported manually (e.g. self-inflating bag-valve-mask) or mechanically (e.g. ventilator). The preceding section on the airway has outlined the requirements for the bag-valve-mask. Mechanical ventilators have considerable utility for the physiological support of seriously injured patients. They are listed as desirable at the upper three levels of the health system. However, their cost prevents them from being considered essential for countries at all economic levels. The use of mechanical ventilators implies not only that they are physically present, but also that mechanisms exist to assure continual functioning by rapid repair, and that personnel are trained in their use. This would include respiratory therapists or nursing or other staff with adequate training in the use and routine maintenance of ventilators. The use of ventilators also implies doctors and nurses with sufficient training to care for mechanically ventilated patients. The latter implies the assessment of oxygenation status, the ability to recognize and correct problems (e.g. endotracheal tube obstruction), and skills in routine maintenance of ventilated patients, such as sterile suctioning, physiotherapy and postural drainage to reduce the risk of pneumonia.

TABLE 2 Breathing—Management of respiratory distress

Facility level

Breathing: knowledge & skills

Basic

GP

Specialist

Tertiary

Assessment of respiratory distress and adequacy of ventilation

E

E

E

E

Administration of oxygen

D

E

E

E

Needle thoracostomy

D

E

E

E

Chest tube insertion

I

E

E

E

Three-way dressing

E

E

E

E

Breathing: equipment & supplies

Stethoscope

E

E

E

E

Oxygen supply (cylinder, concentrator or other source)

D

E

E

E

Nasal prongs, face mask, associated tubing

D

E

E

E

Needle & syringe

D

E

E

E

Chest tubes

I

E

E

E

Underwater seal bottle (or equivalent)

I

E

E

E

Pulse oximetry

I

D

D

D

Arterial blood gas measurements

I

D

D

D

Bag-valve-mask

D

E

E

E

Mechanical ventilator

I

I

D

D

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