Hrev_master Abstract Accurate triage of respiratory emergencies during emergency calls is critical but may be compromised when dispatchers misin- terpret lay language. Nonspecific descriptors may be perceived as the presence of breathing despite indicating severe conditions like airway obstruction or agonal breathing. The objective of this study was to identify common descriptors used by callers in underesti- mated respiratory emergencies and assess how these terms may contribute to under-triage. This retrospective cohort study analysed 382 emergency calls received between 2018 and 2023 at the 118 Emilia Est Emergency Medical Communication Centre in Bologna, Italy. All included calls were initially assigned low-to- moderate urgency for a respiratory problem but were later classi- fied as critical or in cardiac arrest by ambulance crews, requiring advanced life support interventions. Experienced dispatchers inde- pendently reviewed audio recordings to identify lay descriptors, dispatcher questioning patterns, and pre-arrival instructions. In 29.3% of cases, callers used vivid, nonclinical language to describe respiratory distress. The most frequent lay term was “phlegm” (n=68), followed by “rattle” (n=22), and “cough” (n=7). Dispatcher questioning remained limited, and prearrival instruc- tions were rare (5.2%). Oxygen saturation was reported in 19.4% of calls. Terms such as “phlegm” may reflect severe respiratory compromise when used by lay callers but are often under-recog- nized by dispatchers. Training should emphasize the interpretation of informal language and encourage structured follow-up ques- tions to reduce under-triage and improve the early identification of critical respiratory events. Introduction Abnormal respiratory patterns are often among the earliest warning signs of Out-Of-Hospital Cardiac Arrest (OHCA) and other life-threatening emergencies.1 Yet, recognizing these signs during emergency calls remains a major challenge for Emergency Medical Communication Centres (EMCC) dispatchers.2 Studies show that callers initially describe up to 60% of cardiac arrest vic- tims as breathing, often using terms such as “snoring,” “weak breathing,” or “laboured breathing”.3 These ambiguous or mislead- ing descriptions may delay or prevent the recognition of cardiac arrest.4 Agonal respirations, in particular, are frequently mistaken for signs of life. They occur in nearly half of OHCA cases of car- diac origin and are associated with better survival outcomes com- pared to those without agonal breathing.5 However, their presence often contributes to the under-recognition of cardiac arrest, affect- ing dispatcher decision-making in 15–25% of cases.6,7 Standard dispatcher protocols typically rely on brief, binary questions to assess consciousness and breathing (e.g., “Is the patient breathing normally?”), which, although effective in many cases, may fail to capture more subtle indicators of severity.8 The variability in how laypeople describe respiratory distress further complicates triage, as callers often lack medical vocabulary and report symptoms using nonspecific or nonclinical language.9 Callers often provide non-medical or ambiguous descriptions (e.g., “he/she's gasping” and “he/she's turning blue”), which may be mis- interpreted due to protocol rigidity or linguistic mismatch.10 Emergency Care Journal 2025; volume 21:14212 [Emergency Care Journal 2025; 21:14212] [page 75] The importance of lay descriptors of respiratory symptoms: a retrospective analysis of under-triaged emergency calls Guglielmo Imbriaco,1 Juliette Masina,1 Giorgia Ghedini,1 Gianluca Federiconi,1 Jihan Samira Kayal,1 Diana Demaria,1 Jacopo Davide Giamello2 1118 Emilia Est Emergency Medical Communication Center, Maggiore Hospital, Bologna; 2Department of Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy Correspondence: Jacopo Davide Giamello, Department of Emergency Medicine, Santa Croce e Carle Hospital, Cuneo, Italy. E-mail: jacopo.giamello@gmail.com Key words: agonal breathing; dispatch; emergency medical commu- nication centre; emergency medical services; respiratory distress. Funding: this research did not receive any specific grant from fund- ing agencies in the public, commercial, or not-for-profit sectors. Contributions: GI, JDG, conceptualization, formal analysis, data curation, supervision, validation, writing- original draft preparation, writing – review & editing; JM, GG, GF, JSK, DD, Conceptualization, Investigation, Formal analysis, Writing- Original draft preparation. All authors made a significant contribution to the conception, study design, data collection, analysis and interpreta- tion, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be pub- lished and agreed to be accountable for all aspects of the work. Conflict of interest: GI is a member of the Scientific Committee of the Italian Resuscitation Council and the board of ANIARTI, the Italian Association of Critical Care Nurses. All other authors have no competing interests to declare. Ethics: the study was conducted in accordance with the Declaration of Helsinki, and approved by the Local Ethics Committee (CE- AVEC - Protocol 568-2023-OSS-AUSLBO). Consent to participate: patient consent was waived by the Local Ethics Committee due to organizational impracticability. The study involved a retrospective analysis of emergency calls, where many patients were deceased or uncontactable, and callers were often not directly linked to the patients. Received: 31 July 2025. Accepted: 6 October 2025. Early view: 4 November 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Emergency Care Journal 2025; 21:14212 doi:10.4081/ecj.2025.14212 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Dispatcher training and protocol design must therefore account for this linguistic variability to improve the early recognition of criti- cal conditions. Despite strong evidence that dispatcher-assisted cardiopul- monary resuscitation (DA-CPR) improves OHCA outcomes,11,12 patients described as “still breathing” are significantly less likely to receive DA-CPR instructions.8 This highlights a critical gap in the early chain of survival: misinterpreting abnormal breathing may lead to under-triage and missed opportunities for life-saving intervention.13 To improve early recognition, dispatchers must be equipped not only with better protocols but also with a deeper understanding of the verbal cues and descriptive language commonly used by the public. This study examines underestimated respiratory emergen- cies in EMCC calls to identify recurring lay descriptors and other elements that may help recognize high-severity cases. Materials and Methods This retrospective cohort study was conducted at 118 Emilia Est Emergency Medical Communication Center in Bologna, Italy: this wide-area emergency dispatch centre serves approximately 2 million people and handled 239,303 missions in 2024. In Italian Emergency Medical Services (EMS), dispatchers use a color- coded urgency scale (white, green, yellow, and red), while EMS crews assign a post-evaluation numerical severity score ranging from 0 (no need for transport to hospital) to 4 (death). The analysis was based on a review of the audio files of all emergency calls received between January 2018 and December 2023 classified as under-triaged, that met the following criteria: i) the dispatcher identified a primary respiratory problem, ii) assigned a low-to-moderate priority code (white, green, or yellow), and iii) EMS responders on the scene documented the patient as critical or in cardiac arrest, requiring advanced life support interventions. Two senior dispatchers independently reviewed all included call recordings using a standardized data collection form, specifi- cally developed for this study. Reviewers focused on: i) sponta- neous or prompted descriptions of respiratory distress by callers, beyond the standard question “Is the patient breathing normally?”, including descriptions of respiratory sounds, alterations in skin colour, respiratory rate, and other lay terms or expressions used to describe breathing difficulty; notably, calls were flagged for “dis- tinctive lay descriptors” if the caller used vivid, sensory, or metaphorical expressions to describe respiratory distress and if these were assessed by both researchers as potentially indicative of high clinical severity; ii) availability of home pulse oximeters and any oxygen saturation values reported by the caller; whether pre- arrival instructions were provided (e.g., positioning, oxygen sup- port). If discrepancies arose, reviewers reached consensus through discussion. This study was approved by the local ethics committee (CE- AVEC - Protocol 568-2023-OSS-AUSLBO). Results A total of 382 emergency calls met the inclusion criteria. All were initially categorized by dispatchers as low-to-moderate-prior- ity respiratory events; however, subsequent EMS evaluation revealed a critical condition or a cardiac arrest, indicating a mis- judgement in initial EMCC triage. The median call duration was 127 seconds [IQR: 95-188]. Dispatchers’ questioning was generally limited to basic prompts, primarily “Is he/she breathing normally?”. More in-depth assessments were rare: the dispatcher actively listened to respira- tory sounds by asking the caller to place the phone near the patient in 3.7% (n=14) of calls; abnormal respiratory sounds, either spon- taneously reported or prompted, were identified in 26.4% of cases (n=101). Signs of cyanosis or abnormal skin colour were men- tioned in 4.2% (n=16), breathing rhythm in 7.1% (n=27), and the quality of breathing (e.g., accessory muscle use or open-mouth breathing) in 12.8% of calls (n=49) (Table 1). Oxygen saturation was reported or asked in 19.4% of calls (n=74). Notably, during the post-pandemic period, reports of oxy- gen saturation values increased (from 15% in 2018-2019 to 26,1% in 2022-2023), often volunteered by the caller without prompting. Pre-arrival instructions were issued in 5.2% of calls (n=20) and mainly involved modifying patient’s posture (4.5%, n=17) or advising to start or adjust oxygen therapy (0.8%, n=3). Among all reviewed calls, 29.3% (n=112) featured one or more distinctive lay descriptions that the reviewers identified as indicative of possible high clinical severity. Within these, a series of recurring verbal expressions were identified (Figure 1A and 1B). The most frequent term was “phlegm” (n=68); other recurrent lay descriptors included: “rattles” (n=22), “cough” (n=7), “gur- gling” and “make noise when breathing” (each n=5), “whistling” and “shortness of breath” (each n=4). Descriptors such as “soap bubbles in the throat” (n=3), “throat obstruction” (n=3), and “gasps” (n=2), while less common, were also reported. Article [page 76] [Emergency Care Journal 2025; 21:14212] Table 1. Dispatcher assessment of respiratory distress in under-triaged emergency calls (n = 382). Dispatcher action / caller information (spontaneous or prompted) N (%) Listened to respiratory sounds or asked caller to bring the phone closer 14 (3.7) Abnormal respiratory sounds reported or inquired 101 (26.4) Cyanosis / abnormal skin colour reported or inquired 16 (4.2) Breathing rhythm reported or inquired 27 (7.1) Breathing quality reported or inquired 49 (12.8) Oxygen saturation value reported or inquired 74 (19.4) Pre arrival instructions provided 20 (5.2) Modifying patient’s posture 17 (4.5) Administering / increasing oxygen therapy 3 (0.8) Discussion This study highlights a critical blind spot in emergency call triage: the under-recognition of respiratory distress when described using non-clinical or ambiguous language. Lay expressions such as “phlegm,” “gasping,” “making noises like choking,” or “turning blue” may correspond to conditions requiring urgent intervention, like severe hypoxia, airway obstruction, or agonal respirations. Such terms often fall outside standard dispatch protocols or fail to trigger appropriate or additional questions. As a result, dispatchers may assign a low-priority code, delaying emergency response and potentially contributing to avoidable adverse outcomes. The challenge of recognizing cardiac arrest during emergency calls is well documented and dispatchers’ sensitivity in identifying cardiac arrest varies widely.14,15 Agonal respirations are frequently misinterpreted as signs of life, especially when described with lay terms.16 This misperception may hinder DA-CPR and delay life- saving interventions.17 Protocolized prompts such as “Is the patient breathing normal- ly?” are often insufficient to detect severe respiratory compromise. A more nuanced approach could incorporate structured questions addressing rate, sound, posture, skin colour, and pulse-oximeter reading. For instance: is the breathing fast, slow, or noisy? Do you hear wheezing, gurgling, or rattling? Are the lips or fingertips pale or bluish? Do you have a pulse oximeter? Can you read the value? Such additions could enhance the early recognition of life- threatening respiratory distress, reducing under-triage and improv- ing outcomes. Beyond updating protocols, this study underscores the importance of training dispatchers to recognize and interpret common lay expressions that may be associated with life-threaten- ing conditions, even if these do not align with standard clinical ter- minology. For example, healthcare professionals may interpret the term “phlegm” as indicative of a minor respiratory infection. However, in emergency calls, this term is often used by laypersons to describe loud, gurgling, or snoring sounds, potentially reflecting airway obstruction or agonal breathing. Such onomatopoeic descriptors, though informal, may offer critical diagnostic clues and should prompt further assessment. These findings align with a recent work that analysed 375 emergency calls dispatched as OHCA, identifying 23 categories of breathing descriptors used by callers.18 Its results demonstrated that even ambiguous or vague descriptors such as “barely breath- ing,” “gasping,” or “laboured” were associated with a high proba- bility of actual cardiac arrest, often exceeding 60–70%. Notably, even expressions of uncertainty (e.g., “not sure if breathing”) car- ried a predictive value of 76.8%, while descriptors like “dead” and “not breathing” exceeded 85%. These results reinforce the impor- tance of adopting a precautionary approach when evaluating breathing in unconscious patients and support the argument that any qualified or non-normal breathing description should raise immediate suspicion of life-threatening compromise. Further insight is offered in a state-of-the-art review by Riou (2024), which highlights how linguistic framing, caller epistemic positioning, and turn design influence the effectiveness of tele- phone triage in emergency calls.10 For example, affirmative responses to the question “Is the patient breathing?” are often qual- ified with subsequent information indicating abnormal respiration, an interactional feature that may mislead dispatchers if protocols do not account for conversational nuance. Moreover, callers fre- quently make early epistemic claims (e.g., “I think it’s too late” or “he/she's gone”), which have been shown to correlate with reduced compliance to dispatcher-initiated CPR instructions.9 Riou’s syn- thesis also highlights the limitations of rigid scripted dispatch sys- tems, which may fail to accommodate lay expressions and reduce opportunities for clarification and collaborative sense-making. In this context, under-triage should be understood not only as a clini- cal misjudgement but also as a communicative breakdown, high- lighting the urgent need for dispatcher training that incorporates interactional and linguistic strategies. Lastly, over the six years analysed, some changes in the tools available to callers were observed. The post-pandemic increase in spontaneous reporting of oxygen saturation values suggests a shift in how the public monitors and communicates respiratory symp- toms.19 While home pulse oximeters are not flawless, they offer a potentially valuable supplement to verbal descriptions, particularly when interpreted cautiously by trained dispatchers.20 Article [Emergency Care Journal 2025; 21:14212] [page 77] Figure 1. Recurring verbal expressions identified in under-triaged emergency calls. A: distribution; B: word cloud. Limitations This study, although based on systematic case selection and detailed audio review, has limitations. It was conducted at a single centre and focused exclusively on underestimated respiratory emergencies, potentially excluding cases where dispatchers appro- priately escalated care. A comparator group of correctly triaged respiratory calls was not included, as identifying and reviewing a sufficiently large and representative sample posed substantial orga- nizational challenges. Moreover, information volunteered by callers or elicited by dispatchers was not differentiated, as this boundary is often blurred in real practice. Additionally, linguistic and cultural variations may influence how respiratory distress is described, limiting the generalizability of specific lay terms identi- fied in this study. Despite these constraints, the findings provide a strong rationale for improving how lay descriptions are captured and interpreted during emergency calls. Conclusions This analysis of 382 emergency calls related to respiratory complaints later deemed critical or fatal identified a consistent set of lay terms that may help recognize clinical severity early. Words such as “phlegm,” “rattle,” and “gurgles,” though often dismissed as nonspecific, were frequently used by callers describing agonal breathing or airway obstruction. These expressions, alongside objective indicators like oxygen saturation, were present but underutilized. Sharing this knowledge with dispatchers and inte- grating these verbal cues into structured questioning protocols could prompt earlier recognition, additional questions, and more accurate prioritization. Developing a reference list of high-risk lay descriptors may improve training and bridge the gap between pub- lic language and clinical urgency. Further research should explore how integrating these terms into dispatch systems affects patient outcomes. References 1. Berdowski J, Beekhuis F, Zwinderman AH, et al. Importance of the first link: Description and recognition of an out-of-hos- pital cardiac arrest in an emergency call. Circulation 2009;119:2096-102. 2. Viereck S, Møller TP, Ersbøll AK, et al. Recognising out-of- hospital cardiac arrest during emergency calls increases bystander cardiopulmonary resuscitation and survival. Resuscitation 2017;115:141-7. 3. Fukushima H, Imanishi M, Iwami T, et al. Abnormal breathing of sudden cardiac arrest victims described by laypersons and its association with emergency medical service dispatcher- assisted cardiopulmonary resuscitation instruction. Emerg Med J 2015;32:314-7. 4. Riou M, Ball S, Williams TA, et al. ‘Tell me exactly what’s happened’: When linguistic choices affect the efficiency of emergency calls for cardiac arrest. Resuscitation 2017;117:58- 65. 5. Debaty G, Labarere J, Frascone RJ, et al. Long-term prognos- tic value of gasping during out-of-hospital cardiac arrest. J Am Coll Cardiol 2017;70:1467-76. 6. Tanaka Y, Taniguchi J, Wato Y, et al. The continuous quality improvement project for telephone-assisted instruction of car- diopulmonary resuscitation increased the incidence of bystander CPR and improved the outcomes of out-of-hospital cardiac arrests. Resuscitation 2012;83:1235-41. 7. Vaillancourt C, Verma A, Trickett J, et al. Evaluating the Effectiveness of Dispatch-assisted Cardiopulmonary Resuscitation Instructions. Acad Emerg Med 2007;14:877-83. 8. Bång A, Herlitz J, Martinell S. Interaction between emergency medical dispatcher and caller in suspected out-of-hospital car- diac arrest calls with focus on agonal breathing. A review of 100 tape recordings of true cardiac arrest cases. Resuscitation 2003;56:25-34 9. Riou M, Ball S, Williams TA, et al. ‘She’s sort of breathing’: What linguistic factors determine call-taker recognition of ago- nal breathing in emergency calls for cardiac arrest? Resuscitation 2018;122:92-8. 10. Riou M. Communication in prehospital and emergency care: a state-of-the-art literature review of conversation-analytic research. Res Lang Soc Interac 2024;57:55-72. 11. Sasson C, Rogers MAM, Dahl J, Kellermann AL. Predictors of survival from out-of-hospital cardiac arrest a systematic review and meta-analysis. Circ Cardiovasc Qual Outcomes 2010;3:63-81. 12. Bobrow BJ, Spaite DW, Berg RA, et al. Chest compression- only CPR by lay rescuers and survival from out-of-hospital cardiac arrest. JAMA 2010;304:1447. 13. Roppolo LP, Westfall A, Pepe PE, et al. Dispatcher assess- ments for agonal breathing improve detection of cardiac arrest. Resuscitation 2009;80:769-72. 14. Vaillancourt C, Charette M, Kasaboski A, et al. Cardiac arrest diagnostic accuracy of 9-1-1 dispatchers: A prospective multi- center study. Resuscitation 2015;90:116-20. 15. Drennan IR, Geri G, Brooks S, et al. Diagnosis of out-of-hos- pital cardiac arrest by emergency medical dispatch: A diagnos- tic systematic review. Resuscitation. 2021;159:85-96. doi:10.1016/j.resuscitation.2020.11.025 16. Alfsen D, Møller TP, Egerod I, Lippert FK. Barriers to recog- nition of out-of-hospital cardiac arrest during emergency med- ical calls: A qualitative inductive thematic analysis. Scand J Trauma Resusc Emerg Med 2015;23:70. 17. Syväoja S, Salo A, Uusaro A, Jäntti H, Kuisma M. Witnessed out-of-hospital cardiac arrest˗ effects of emergency dispatch recognition. Acta Anaesthesiol Scand 2018;62:558-67. 18. Perera N, Riou M, Birnie T, et al. How likely is the patient to be in cardiac arrest? Caller breathing descriptors in ambulance calls that were dispatched as cardiac arrest. Resusc Plus 2025;24:100990. 19. Alboksmaty A, Beaney T, Elkin S, et al. Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review. Lancet Digit Heal 2022;4:e279-89. 20. Cilloniz C, Simonds A, Hansen K, et al. Pulse oximetry is an essential tool that saves lives: A call for standardisation. Eur Respir J 2021;57:2100815. Article [page 78] [Emergency Care Journal 2025; 21:14212]