5.1 Breathing Status in the Primary Assessment

What "Breathing" Means in the Primary Assessment

The B in the primary assessment (XABCDE) is a rapid judgment: is this patient moving enough air to live in the next few minutes? The Emergency Medical Responder (EMR) is not diagnosing pneumonia versus asthma here. The single question is whether breathing is adequate or inadequate, because an inadequate-breathing patient needs help moving air now, during the primary assessment, not later.

Adequate breathing has four features the EMR checks almost simultaneously:

• Rate within normal limits for age
• Rhythm that is regular
• Depth (tidal volume) that produces visible, even chest rise
• Effort that is relaxed and unlabored, with clear and equal breath sounds

Normal adult tidal volume is roughly 5-7 mL per kilogram of body weight. You do not measure this; you judge it by watching the chest and listening. Air that you can see, hear, and feel moving in adequate amounts is the goal. A patient breathing 16 times a minute with full chest rise, talking in complete sentences, and pink skin has adequate breathing. A patient breathing 30 shallow times a minute, using neck muscles, and speaking two words at a time does not, even though the rate is fast — fast and shallow can move less air than slow and deep.

Normal Respiratory Rates by Age

Rate alone never decides adequacy, but it is the first number you report. Memorize the resting ranges:

A rate below 8 or above 24 in an adult is a red flag for inadequate breathing and almost always pairs with another abnormal sign. In children, watch the effort: kids compensate by breathing faster long before they tire, so a child whose rate suddenly slows toward normal while still looking sick may be exhausting and heading toward respiratory failure — an ominous finding, not reassurance.

Recognizing Inadequate Breathing

Inadequate breathing is the high-yield exam concept. Signs include:

• Rate too fast or too slow for age
• Shallow depth with minimal chest rise (poor tidal volume)
• Irregular rhythm; diminished, unequal, or absent breath sounds
• Increased work of breathing: accessory-muscle use, retractions (skin pulling in between/above ribs and at the neck), nasal flaring, seesaw breathing and grunting in infants
• Noisy airway sounds: stridor (high crowing), snoring, gurgling, wheezing
• Skin signs: cyanosis (blue/gray lips, nail beds), pallor, cool clammy skin
• Altered mental status: restlessness, anxiety, confusion, then sleepiness — a hypoxic brain
• Speech: one- or two-word dyspnea instead of full sentences
• Tripod positioning (leaning forward on the arms) to maximize air movement

Agonal respirations — slow, sporadic, gasping breaths just before arrest — are NOT effective breathing. They are a cardiac-arrest sign. Treat them as an absence of breathing.

When and How the EMR Intervenes

The EMR scope for breathing is broad and powerful: positioning, suctioning, airway adjuncts (OPA/NPA), supplemental oxygen, and bag-valve-mask (BVM) ventilation. The decision rule is simple:

• Adequate breathing, signs of hypoxia or distress -> give supplemental oxygen (titrate to SpO2 >=94%) and monitor.
• Inadequate breathing (too slow, too shallow, failing) -> assist ventilations with a BVM at the correct rate, even if the patient is still breathing on their own.
• Absent or agonal breathing -> ventilate (or begin CPR if pulseless).

Assisted BVM ventilation rates the EMR must know: about 10-12 breaths/min for an adult who is not breathing (one breath every 5-6 seconds), and 12-20 breaths/min for infants and children (one every 3-5 seconds). For a patient breathing too slowly, time your squeezes to assist their own efforts and fill in the missing breaths. Each ventilation should produce visible chest rise — and no more, to avoid forcing air into the stomach (gastric distension), which causes vomiting and aspiration.

Worked scenario

A 58-year-old is found semi-conscious, breathing 6 times a minute, shallow, with blue lips after a suspected opioid overdose. Trap: "He's breathing, so just put on a non-rebreather." Wrong — 6 shallow breaths is inadequate ventilation. The correct EMR action is BVM ventilation at about one breath every 5-6 seconds, assist naloxone per protocol, and request advanced resources. Oxygen alone does not move air; ventilation does.

Oxygen Therapy: Matching the Device to the Patient

Once breathing is supported, the EMR delivers supplemental oxygen to correct or prevent hypoxia. The device is chosen by how much oxygen the patient needs and whether they are breathing adequately on their own. Know these three devices and their numbers precisely:

Key rules: a nasal cannula above 6 L/min dries the nostrils without adding meaningful oxygen, so it is capped at 6. Before applying a non-rebreather, pre-inflate the reservoir bag to more than two-thirds full, and set flow high enough (10-15 L/min) that the bag does not fully collapse on inhalation. Titrate oxygen to keep SpO2 at or above 94%; do not reflexively run high-flow oxygen on a patient who is already well-saturated.

The decisive concept: the cannula and NRB are for patients who are breathing adequately on their own; the BVM is the tool when breathing is inadequate or absent, because only the BVM actually moves air for the patient.