7 Respiratory Emergencies
Learn to recognize adult respiratory distress and failure, provide initial support, and respond to common respiratory and airway emergencies.
Recognizing distress and failure
Respiratory emergencies can worsen rapidly. The priorities are to recognize failing breathing, maintain oxygenation and ventilation, identify a reversible cause, and summon advanced help early. This guidance focuses on initial care for adults; follow local protocols and use age-specific guidance for children.
Assess the patient as a whole, not just the pulse-oximeter reading. Warning signs include rapid or labored breathing, accessory-muscle use, inability to speak normally, tripod posture, cyanosis, sweating, agitation, confusion, exhaustion, or decreasing responsiveness. Stridor, a weak or absent cough, drooling, facial or tongue swelling, and sudden loss of breath sounds may signal an airway threat. In a patient with severe wheezing, a quiet chest can indicate critically poor airflow rather than improvement.
can be hypoxemic, hypercapnic (ventilatory), or both. Oxygen saturation alone does not rule out carbon-dioxide retention or fatigue; worsening effort, mental status, and trends matter.
Initial assessment and support
Use an airway, breathing, circulation (ABCs) approach, and activate emergency response or EMS early for severe distress, suspected airway obstruction, rapidly worsening symptoms, altered consciousness, or inadequate breathing. Check responsiveness, airway patency, breathing rate and effort, circulation, and oxygen saturation. Obtain a brief history of onset, triggers, fever, choking, allergies, lung or heart disease, medications, and prior episodes, but do not let this delay urgent care.
Let a conscious patient sit upright if tolerated. Reassess frequently and continuously monitor oxygen saturation when available. Record both the oxygen device and flow as well as the saturation reading.
Give oxygen for hypoxemia and titrate it to a target rather than using the same high concentration for everyone. A common adult target is . For known or suspected risk of hypercapnic failure, use while blood-gas results and an individualized plan are obtained, unless immediate life-threatening hypoxemia requires urgent correction. Follow local guidance.
If breathing is absent or ineffective, trained responders should provide rescue ventilations and reassess. For an adult with a pulse, the AHA recommends one breath about every seconds, with enough volume to produce visible chest rise. If the person is unresponsive and not breathing normally, activate emergency response and begin CPR/AED steps according to training.
Consider reversible causes, including asthma or COPD flare, , anaphylaxis, foreign-body obstruction, pneumothorax, heart failure, pulmonary embolism, medication or opioid effects, and neuromuscular weakness. Do not assume a single diagnosis from wheezing or low oxygen alone.
Asthma causes episodic, usually reversible airway narrowing. An exacerbation often presents with wheeze, cough, chest tightness, and shortness of breath. Severe signs include speaking only in words, marked accessory-muscle use, agitation or drowsiness, low oxygen saturation, poor air movement, or a silent chest.
Give the patient’s prescribed rapid-relief inhaler if available and administer inhaled short-acting bronchodilator treatment under the applicable protocol. For severe attacks, clinicians commonly add ipratropium and systemic corticosteroids. Intravenous magnesium may be considered for a severe attack that responds poorly to initial treatment.
Reassess frequently, including speech, work of breathing, oxygenation, and, when feasible, peak flow or lung function. Escalate urgently for exhaustion, altered consciousness, worsening hypoxemia, or poor response. Noninvasive ventilation is not routine for asthma; any trial requires close expert monitoring and must not delay definitive airway management. Antibiotics are not routine unless there is evidence of a concurrent infection.
COPD exacerbations commonly cause increased breathlessness, cough, and changes in sputum amount or purulence. Consider mimics or coexisting emergencies, including , heart failure, pulmonary embolism, and pneumothorax. Treat with short-acting inhaled bronchodilators. Clinicians may add systemic corticosteroids and, when bacterial infection is suspected, antibiotics. Titrate oxygen carefully, especially for people with prior carbon-dioxide retention, and obtain blood gases when indicated.
is an important hospital treatment for selected patients with acute hypercapnic , particularly when breathing remains labored and blood gases show respiratory acidosis. It requires close monitoring. Do not use NIV when the patient cannot protect the airway, is vomiting, is in severe instability, or is deteriorating; call for urgent expert airway support instead. Do not delay intubation when NIV is failing or unsafe.
may cause fever or chills, cough, sputum, pleuritic chest pain, rapid breathing, crackles, low oxygen, and confusion, especially in older adults. Initial management is supportive and requires urgent assessment: monitor oxygenation and vital signs, provide oxygen if needed, and assess for sepsis or . Clinicians determine whether imaging is needed and start appropriate antimicrobial treatment when bacterial is suspected. Antibiotics are not automatically indicated for every viral respiratory illness. Lung ultrasound can be an alternative to chest radiography in settings with appropriate expertise.
Airway threats and ventilation
Upper-airway obstruction can result from choking, swelling (including anaphylaxis), secretions, or injury. Stridor, inability to speak or cough effectively, rapidly increasing swelling, or decreasing consciousness requires immediate emergency action.
For a conscious adult with severe foreign-body airway obstruction, current AHA guidance is cycles of back blows followed by abdominal thrusts until the object is expelled or the person becomes unresponsive. If the person becomes unresponsive, begin CPR and follow emergency-response instructions. Remove an object only when it is visible; do not perform a blind finger sweep.
Trained responders may use airway positioning, suction, airway adjuncts, and bag-mask ventilation while help arrives. If basic support does not restore effective breathing, or the patient cannot protect the airway, qualified clinicians may need to provide advanced airway management. Noninvasive ventilation supports breathing through a mask in selected patients who are awake enough to cooperate and protect their airway. Invasive ventilation through an endotracheal tube is considered when noninvasive support is unsuitable or fails, or when airway protection is lost. Both approaches require trained teams and ongoing reassessment.
Escalation priorities
Recognize through the whole clinical picture: work of breathing, speech, mental status, air movement, and oxygenation trends. Use an ABC approach, summon help early, give titrated oxygen, support ventilation when breathing is ineffective, and treat the likely cause. Airway obstruction, exhaustion, altered consciousness, and failure to improve are emergencies that require escalation.