06 Respiratory Emergencies

Priorities in respiratory emergencies

Respiratory emergencies range from increased work of breathing to respiratory failure. Priorities are to recognize failing ventilation or oxygenation early, support airway and breathing, identify the likely cause, reassess response, and transport without delaying definitive care. Medication choice, dosing, oxygen targets, and airway interventions should follow current medical direction and local protocols.

Assess the patient and track change

Begin with scene safety and the patient’s position of comfort. Assess mental status, airway patency, respiratory effort, skin signs, pulse, and ability to speak. Look for accessory-muscle use, retractions, tripod positioning, cyanosis, diaphoresis, and fatigue.

Count respiratory rate, but also assess depth and pattern. Listen to the chest, compare sides, and note wheezes, crackles, stridor, diminished air movement, or absent sounds. Poor chest rise, weak or irregular respirations, declining consciousness, or inability to protect the airway suggest inadequate ventilation and the need for immediate ventilatory support.

A patient who becomes quiet, confused, drowsy, or exhausted may be deteriorating rather than improving. In a patient with severe wheezing, a silent chest can indicate critically poor airflow.

Measure oxygen saturation and track it alongside appearance and work of breathing. Pulse oximetry estimates oxygenation, not ventilation, and can be misleading with poor perfusion, motion, or other technical limitations. Use waveform capnography when available to assess ventilation and trends, while interpreting values in clinical context. A normal-looking saturation does not rule out hypoventilation or impending failure.

Build and refine the differential

Ask about onset and progression, fever or cough, chest pain, sputum, wheezing, choking, allergic symptoms, medications and response to them, prior intubation or hospitalization, and relevant cardiac or lung disease. Include medication and exposure history, including smoking or vaping.

Consider infection, asthma, COPD, pulmonary edema, pulmonary embolism (PE), pneumothorax, anaphylaxis, foreign-body obstruction, and nonpulmonary causes such as acute coronary syndrome, dysrhythmia, or metabolic illness. Use findings to refine the differential rather than closing it prematurely.

Diffuse wheezing may occur with asthma, COPD, or pulmonary edema; crackles may accompany infection or edema. Fever and cough support infection, but findings may be subtle in older or immunocompromised patients. Sudden dyspnea, pleuritic chest pain, syncope, hemoptysis, or venous-thromboembolism risk factors should raise concern for PE. Unilateral markedly diminished breath sounds, especially with sudden deterioration or shock, raise concern for pneumothorax.

Treat, reassess, and escalate

Keep the patient at rest in a position that eases breathing, provide reassurance, and limit exertion. Give supplemental oxygen when indicated and titrate it to the target in local protocol. Patients at risk of hypercapnic respiratory failure may require controlled oxygen and close reassessment, but do not withhold oxygen from a hypoxemic patient.

Treat the suspected cause when the presentation and protocol support it, such as using an inhaled bronchodilator for bronchospasm or CPAP for an appropriate patient with severe respiratory distress. Reassess frequently: mental status, speech, respiratory effort and rate, lung sounds, pulse, blood pressure, oxygen saturation, and capnography when available. Judge response using the whole clinical picture, not a single number.

If breathing is inadequate, assist ventilation with a well-sealed bag-mask device, using only enough volume for visible chest rise and avoiding excessive rate or volume. Prepare for advanced airway management if the patient cannot maintain the airway or oxygenation or ventilation despite appropriate support. Do not delay effective basic ventilation while preparing an advanced airway.

Noninvasive ventilation, such as CPAP, can reduce work of breathing and improve oxygenation in selected cooperative patients who can protect their airway and tolerate the interface. It is not appropriate for every patient or cause. Monitor for intolerance, vomiting, worsening hypotension, or failure to improve, and be ready to escalate. Positive pressure can worsen hypotension in some patients.

Asthma and COPD exacerbations

Asthma typically causes episodic, often reversible bronchoconstriction. COPD commonly involves chronic airflow limitation, with exacerbations marked by worsening dyspnea, cough, or sputum. Both can cause wheezing and prolonged expiration.

Assess air movement and fatigue: wheezing may diminish as airflow becomes critically limited. In severe asthma, altered mental status, exhaustion, poor air movement, or a silent chest are ominous. A patient who initially breathes rapidly but later tires or becomes less responsive may be progressing toward ventilatory failure.

Give inhaled short-acting bronchodilator therapy according to protocol. Add an anticholinergic agent and systemic corticosteroid when indicated by severity and protocol. Titrate oxygen rather than giving it indiscriminately to a patient at risk of carbon-dioxide retention. Consider ventilatory support and prompt transport for poor response, exhaustion, altered mental status, or worsening gas exchange. Avoid unnecessary delays for repeated treatments when the patient is deteriorating.

Pulmonary edema

Acute pulmonary edema often presents with severe dyspnea, hypoxemia, crackles, and sometimes pink frothy sputum. A history of heart failure, cardiac disease, or hypertension may help identify it; wheezing can also occur.

Sit the patient upright if tolerated and support oxygenation. Consider CPAP when indicated and permitted by protocol. Nitroglycerin may be appropriate in selected patients under protocol, after assessing blood pressure and contraindications. Reassess hemodynamics closely because positive pressure and vasodilators can worsen hypotension.

Respiratory infection

Pneumonia and viral lower respiratory infections may cause cough, fever or chills, shortness of breath, pleuritic discomfort, hypoxemia, and focal or diffuse abnormal lung sounds. Confusion or weakness can be prominent, especially in older adults.

Support airway, oxygenation, and ventilation as needed. Assess for signs of sepsis or respiratory failure and expedite transport for instability. Prehospital assessment generally identifies risk and severity rather than the infectious organism. Antibiotics are not routine field treatment unless specifically directed by protocol.

Pulmonary embolism

Pulmonary embolism (PE) may cause sudden unexplained dyspnea, pleuritic pain, tachycardia, hypoxemia, syncope, or shock. Risk is higher with factors such as recent surgery, immobility, cancer, pregnancy or postpartum status, estrogen use, or prior venous thrombosis.

Findings can be nonspecific, and a normal lung examination does not exclude PE. Provide supportive care, monitor for hemodynamic deterioration, and transport promptly for definitive evaluation. Do not assume PE is ruled out by oxygen saturation or lack of leg symptoms.

Recognize deterioration despite quieter lungs

A patient with known COPD is anxious, tachypneic, and wheezing. After initial treatment, wheezing becomes faint, but the patient is more drowsy and has weaker chest rise.

Do not interpret quieter lungs as improvement: reduced air movement and declining alertness suggest fatigue and worsening ventilation. Escalate ventilatory support, reassess continuously, and expedite transport.

Integrate findings and act promptly

Respiratory assessment is dynamic: interpret effort, air movement, mental status, and trends together. Treat hypoxemia, support inadequate ventilation, and target therapy to the most likely cause while remaining alert to dangerous alternatives such as pulmonary edema, infection, pneumothorax, and PE. Reassessment and timely escalation are central to sound paramedic judgment.

• bag-mask ventilation