5 Common Respiratory Emergencies

Recognizing respiratory distress

Respiratory emergencies can worsen quickly. Increased work of breathing, poor air movement, cyanosis, exhaustion, altered mental status, or falling oxygen saturation are warning signs that require prompt attention.

A silent chest, weak respiratory effort, or reduced consciousness may signal impending respiratory failure; these findings should not be interpreted as improvement.

Initial assessment and support

Get help early for severe or worsening distress, activate the emergency response, and do not leave the person alone. Assess airway, breathing, and circulation by checking responsiveness, respiratory rate and effort, ability to speak, skin color, breath sounds, pulse, and oxygen saturation when available. Reassess frequently.

Support the airway and breathing. If the person is conscious, position them for comfort; clear only visible material, and provide oxygen when indicated. If breathing is inadequate, assist ventilation with a bag-mask device if trained and equipped. Escalate promptly if basic support is failing; advanced airway procedures require trained clinicians.

Treat the likely cause while supporting oxygenation. Do not let diagnostic tests delay emergency treatment.

Oxygen and monitoring

Oxygen is a treatment to titrate, not a substitute for ventilation. Target saturation depends on the condition: for adults with acute asthma, the general target is $92\text{–}95\%$; for a COPD exacerbation where hypercapnia is a concern, use controlled oxygen and generally target $88\text{–}92\%$ pending clinical assessment and blood-gas results. Follow local protocols and individual prescribed targets.

Pulse oximetry is useful, but it does not assess ventilation or carbon dioxide retention.

Asthma exacerbation

An asthma exacerbation involves acute worsening of wheeze, cough, chest tightness, or breathlessness. Prolonged expiration and reduced peak expiratory flow may occur. Severe warning signs include difficulty speaking, marked accessory-muscle use, poor air entry or a silent chest, exhaustion, cyanosis, and confusion or drowsiness.

Give an inhaled rapid-acting bronchodilator according to the person’s action plan or local protocol; a metered-dose inhaler with spacer is often suitable. In acute care, add inhaled ipratropium for moderate-to-severe attacks. A clinician may direct early systemic corticosteroids for a significant exacerbation. Titrate oxygen if needed.

Reassess symptoms, air entry, respiratory effort, and oxygen saturation. Arrange urgent transfer for severe features, deterioration, or inadequate response. If asthma occurs with suspected anaphylaxis, give intramuscular epinephrine promptly as well. Epinephrine is not routine treatment for an asthma attack without anaphylaxis.

COPD exacerbation

A COPD exacerbation is a sustained worsening beyond the person’s usual day-to-day variation, commonly involving increased breathlessness, cough, sputum volume, or sputum purulence. Consider other urgent causes of breathlessness, including pneumonia, heart failure, pulmonary embolism, or pneumothorax.

Use short-acting inhaled bronchodilators, with or without a short-acting anticholinergic, as directed by the clinical protocol. Titrate oxygen cautiously; when hypercapnic respiratory failure is a risk, the common target is $88\text{–}92\%$. Obtain blood-gas assessment when indicated.

Clinicians may use a short course of systemic corticosteroids for a significant exacerbation, and antibiotics when indicated—for example, with purulent sputum or ventilatory support. Persistent respiratory failure, worsening acidosis, or severe work of breathing requires urgent hospital-level assessment. Noninvasive ventilation may be appropriate for selected patients.

Anaphylaxis

Suspect anaphylaxis when sudden illness follows a likely allergen exposure and involves airway, breathing, or circulation problems. Possible signs include throat or tongue swelling, hoarse voice, stridor, wheeze, severe breathlessness, faintness, or collapse. Hives, flushing, or swelling are common skin signs, but they may be absent.

Treat suspected anaphylaxis as an emergency. Call emergency services and give intramuscular epinephrine promptly according to the person’s prescribed autoinjector instructions or local clinical protocol. Repeat according to protocol if severe symptoms persist.

Keep the person lying flat where possible; allow a position of comfort if breathing is difficult, and do not let them stand or walk. Give oxygen and support ventilation if available and within training. Antihistamines do not replace epinephrine and must not delay it. Arrange emergency medical evaluation even if symptoms improve.

Upper-airway obstruction and choking

Noisy breathing—especially inspiratory stridor—a weak or absent voice, difficulty swallowing, drooling, choking, retractions, or rapidly increasing distress can signal upper-airway obstruction. Causes include a foreign body, swelling from anaphylaxis, infection, or trauma. Stridor at rest or rapidly worsening symptoms require emergency help.

Call emergency services and keep the person calm and in their preferred position. Do not perform a blind finger sweep or probe an airway that may be swollen.

For a conscious adult with severe choking—an ineffective or absent cough, inability to speak, or signs of worsening obstruction—follow current basic-life-support guidance: give repeated cycles of $5$ back blows followed by $5$ abdominal thrusts. Use chest thrusts instead when appropriate, such as in late pregnancy. If the person becomes unresponsive, begin CPR and remove an object only if it is visible. Use age-specific guidance for infants and children.

Suspected swelling or an anatomically difficult airway needs early expert airway support. Repeated attempts can worsen obstruction.

Putting the response together

Recognize distress early, call for help, assess airway and breathing, support oxygenation and ventilation, and reassess often. Provide cause-specific initial treatment: inhaled bronchodilators for asthma or COPD exacerbation, intramuscular epinephrine without delay for anaphylaxis, and immediate choking first aid for severe foreign-body obstruction.

Escalate early for stridor, poor air movement, exhaustion, altered consciousness, or failure to improve.