Respiratory Emergency Assessment
Respiratory emergencies account for a significant portion of EMS calls and NREMT questions. Your ability to rapidly assess respiratory status, differentiate between conditions, and provide appropriate interventions can determine patient outcomes.
Respiratory Distress vs. Respiratory Failure vs. Respiratory Arrest
Respiratory distress: The patient is working hard to breathe but maintaining adequate oxygenation. Signs include increased respiratory rate, use of accessory muscles, nasal flaring, tripod position, and ability to speak in phrases or sentences. SpO2 is typically above 90%.
Respiratory failure: The patient's compensatory mechanisms are failing. Signs include decreasing respiratory rate despite worsening condition, altered mental status, cyanosis, minimal air movement. SpO2 drops below 90%. This patient is about to arrest.
Respiratory arrest: The patient has stopped breathing. Begin assisted ventilations immediately with BVM and high-flow oxygen.
Asthma
Asthma is reversible airway obstruction caused by bronchospasm, inflammation, and mucus production.
Assessment findings: Wheezing (initially expiratory, then inspiratory and expiratory in severe cases), tachypnea, tachycardia, accessory muscle use, difficulty speaking in full sentences, productive cough
Red flags: Silent chest (no wheezing despite severe distress means air movement is critically reduced), decreasing level of consciousness, cyanosis, bradycardia
EMT management: High-flow oxygen, assist with prescribed metered-dose inhaler (albuterol), position of comfort (usually sitting upright), monitor closely, transport. If the patient has their own prescribed nebulizer and medication, you may assist with administration per protocol.
COPD
Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis. These patients have chronic respiratory compromise that can decompensate acutely.
Emphysema: Destruction of alveolar walls leading to air trapping. Patients are often thin with barrel chest, pursed-lip breathing, and minimal sputum production. Diminished breath sounds bilaterally.
Chronic bronchitis: Chronic inflammation with excessive mucus production. Patients often have productive cough, rhonchi, and may be cyanotic.
EMT management: Administer oxygen as needed. The old teaching that high-flow oxygen will suppress the hypoxic drive in COPD patients and stop their breathing has been largely debunked. Never withhold oxygen from a hypoxic patient. Monitor respiratory effort and assist ventilations if needed.
Pulmonary Edema
Fluid accumulation in the lungs, most commonly caused by congestive heart failure.
Assessment findings: Crackles/rales on auscultation (especially basilar), pink frothy sputum, severe dyspnea, orthopnea, JVD, peripheral edema, hypertension
EMT management: Position sitting upright with legs dangling (decreases venous return to the heart), high-flow oxygen, assist with prescribed nitroglycerin if indicated and blood pressure permits, monitor closely, rapid transport
Pneumonia
Infection of the lung parenchyma. Can be bacterial, viral, or fungal.
Assessment findings: Fever, productive cough, localized crackles, tachypnea, tachycardia, pleuritic chest pain (pain with breathing)
EMT management: Oxygen as needed, position of comfort, monitor for sepsis signs (fever with tachycardia and hypotension), transport for antibiotics and possible imaging