The patient in this picture is unconscious. Normally, we could ask the conscious patient about the status of their airway and breathing, but this is different. As explained before, the airway must be assessed in an unconscious patient. This involved opening the airway with a manual maneuver, then looking, listening, and feeling for breathing to determine that the airway is clear. After performing these simple steps, the ambulance crew can feel confident that their patient’s airway is clear.

Patients who are unconscious are more likely to need ventilation than a patient conscious patient. Supplemental oxygen given by non rebreather mask is preferred in the conscious patient, but what about the unconscious patient? What would happen if the ambulance crew places the non rebreather mask on the patient? The patient could vomit into the mask and aspirate, leading to death (not exactly helpful).

When a patient’s mentation is less than alert, the airway must be constantly monitored. The best way to do that is to administer oxygen with a bag valve mask. The bag valve mask can deliver oxygen like a non rebreather mask. Since the provider is getting a mask seal, the airway is being monitored constantly, increasing patient safety.

The bag valve mask can be used as an oxygen delivery device as well as a means to provide positive pressure ventilation. Positive pressure ventilation is literally the act of forcefully pushing air into the lungs. As one could imagine, the violent act of forcing air into the lungs could detrimental for the patient as the design of the lungs were to suck air from environment.

Positive pressure ventilation should be performed anytime it has been determined the patient’s breathing is inadequate. If a patient is unresponsive and appears to have inadequate respirations, positive pressure ventilation is indicated. Any patient who is unable to speak in complete sentences or has altered mental status may need ventilation. Assessing the rate rhythm and quality of breathing will lead the ambulance crew to determine the efficacy of the patient’s breathing.

How would a rescuer determine the patient’s respiration? First clue is the respiratory rate. If the rate is too slow, the patient won’t be breathing enough volume of air to get the pulmonary capillaries to exchange oxygen and carbon dioxide. One would think a rapid respiratory rate would provide plenty of air flow to facilitate the exchange of oxygen, but the rate is misleading. If the ventilations were extremely shallow, the amount of air would still not be enough to provide sufficient oxygen. If the respirations were noisy, this could indicate aspiration (gurgling) or bronchospasm (wheezing) is present.

Patients in severe distress sometimes show their accessory muscles. The accessory muscles are not the primary muscles of respiration. When the accessory muscles can be seen, the patient is experiencing serious difficulty in breathing. Two things are occurring to make these muscles visible:

• The accessory muscles are actually being used as primary muscles to move the chest. This indicates a failure of the diaphragm and intercostal muscles.
• The patient is working so hard to move air, the skin is literally being sucked to the rib cage due to the vacuum being created in the patient’s chest from the tremendous work of breathing.

Obviously, if the patient is not breathing, positive pressure ventilation is indicated. If the patient is not breathing, the patient could be in cardiac arrest. If the patient is in cardiac arrest, chest compressions are also indicated.