Recognizing Respiratory Distress vs. Respiratory Failure
Respiratory distress is a condition in which the patient is working harder than normal to breathe but is still maintaining adequate oxygenation and ventilation. Signs include increased respiratory rate, use of accessory muscles, nasal flaring, and tripod positioning. Respiratory failure occurs when the patient can no longer maintain adequate oxygenation and ventilation despite maximal effort. Signs include decreasing mental status, cyanosis, decreasing respiratory effort, and bradycardia. The progression from distress to failure requires aggressive intervention.
Asthma
Asthma is a chronic inflammatory condition of the lower airways that causes bronchospasm, inflammation, and mucus production. Acute asthma attacks present with wheezing (may be absent in severe attacks), dyspnea, tachypnea, and prolonged expiratory phase. EMT treatment includes high-flow oxygen, positioning the patient upright, and assisting with the patient's prescribed metered-dose inhaler (MDI) if authorized by medical direction. A silent chest (no wheezing and no air movement) is an ominous sign indicating severe bronchospasm.
COPD Exacerbations
Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis. COPD exacerbations present with increased dyspnea over baseline, productive cough, wheezing, and pursed-lip breathing. Patients may be on home oxygen. Provide supplemental oxygen to maintain adequate oxygenation. The concern about suppressing hypoxic drive in COPD patients is overstated; never withhold oxygen from a hypoxic patient. Assist with prescribed MDI if authorized. Position the patient upright for comfort and optimal ventilation.
Pulmonary Edema
Pulmonary edema is fluid accumulation in the lungs, most commonly caused by congestive heart failure. Signs include severe dyspnea, crackles (rales) on auscultation, pink frothy sputum, orthopnea (difficulty breathing when lying flat), and JVD (jugular vein distension). Position the patient sitting upright with legs dangling to reduce venous return. Provide high-flow oxygen. If the patient is prescribed nitroglycerin and meets criteria, assist with administration per medical direction. Provide CPAP if available and within your scope of practice.
Exam Strategy for Respiratory Questions
When the NREMT presents a respiratory scenario, identify the underlying cause (asthma, COPD, CHF, pneumothorax, etc.) because it determines the specific management. However, all respiratory emergencies share common priorities: ensure scene safety, assess and maintain the airway, provide appropriate oxygen therapy, position the patient for comfort (usually sitting upright), assist with medications as indicated, and transport to an appropriate facility. Monitor for deterioration and be prepared to provide ventilatory support if the patient progresses from respiratory distress to respiratory failure.