EMT · Patient Treatment and Transport · 7 min read · Open lesson
Respiratory Emergencies: Distress, Failure, Asthma and COPD
- Differentiate between respiratory distress, respiratory failure, and respiratory arrest based on clinical findings, tidal volume, and mental status.
- Describe the pathophysiology, signs, and symptoms of asthma and chronic obstructive pulmonary disease, including emphysema and chronic bronchitis.
- Apply basic life support interventions, including oxygen therapy, bag-valve-mask ventilation, continuous positive airway pressure, and assistance with a prescribed metered-dose inhaler.
Recognizing the Continuum: Distress, Failure, and Arrest
Respiratory distress can progress to respiratory failure and arrest, but respiratory failure or arrest can also occur abruptly without obvious preceding distress. Respiratory distress is defined as an increased work of breathing. During distress, the patient's compensatory mechanisms are actively engaged; the individual may initially maintain adequate ventilation, but oxygenation can be impaired. Common clinical signs of respiratory distress include tachypnea, tachycardia, accessory muscle use, and anxiety. At this early stage, the patient's mental status may initially be normal as the body struggles to keep gas exchange sufficient.
Respiratory failure occurs when the respiratory system cannot maintain adequate oxygenation or eliminate carbon dioxide. The transition from distress to failure happens when compensatory efforts begin to fail. Key signs of respiratory failure include altered mental status, inadequate tidal volume, cyanosis, and extreme tachypnea or bradypnea. A critical clinical pearl for emergency medical technicians is that new drowsiness or lethargy in a patient who previously exhibited respiratory distress is a warning sign of worsening respiratory function and possible respiratory failure. Inadequate tidal volume is identified clinically by shallow chest rise, regardless of whether the respiratory rate is fast, normal, or slow. If breathing completely ceases, the patient has entered respiratory arrest, which is the complete cessation of spontaneous breathing.
Recognizing late indicators of severe respiratory compromise is essential for preventing cardiac arrest. Cyanosis of the lips or tongue is a late sign of significant hypoxemia, whereas isolated nail-bed discoloration alone is less specific. Furthermore, while tachycardia is a common early response to hypoxia, the development of new bradycardia in a patient with severe respiratory compromise signals profound hypoxia and impending cardiac arrest. Emergency medical technicians must rapidly distinguish between adequate and inadequate breathing to initiate the proper tier of basic life support care.
| Clinical Feature | Respiratory Distress | Respiratory Failure |
|---|---|---|
| Mental Status | Initially normal; patient is typically anxious and alert | Mental status may initially be normal; new confusion, drowsiness, or lethargy is a warning sign of worsening respiratory failure. |
| Work of Breathing and Rate | Tachypnea with accessory muscle use | Extreme tachypnea or bradypnea; respiratory fatigue |
| Tidal Volume (Chest Rise) | Adequate chest rise and tidal volume maintained | Tidal volume may be inadequate, especially with ventilatory failure; a patient with inadequate oxygenation may initially have adequate chest rise. |
| Gas Exchange | Ventilation initially adequate; oxygenation may be impaired | Inability to maintain adequate oxygenation or eliminate carbon dioxide |
| Primary BLS Intervention | Position of comfort, supplemental oxygen, or protocol-authorized support | Assist ventilation with a bag-valve mask when breathing is absent or inadequate; a patient who is breathing adequately but has impaired oxygenation may need oxygen or protocol-authorized CPAP. |
Oxygen Administration and Positive-Pressure Ventilation Principles
Choose oxygen, protocol-authorized CPAP, or assisted ventilation based on the patient's overall assessment, including the effectiveness of spontaneous breathing, oxygenation, mental status, and ability to tolerate treatment. An emergency medical technician should provide immediate bag-valve-mask ventilation when a patient's breathing is absent or inadequate. Conversely, a patient with adequate spontaneous ventilation may instead need supplemental oxygen or other protocol-authorized support. An oxygen saturation reading below 94% may indicate impaired oxygenation, but this numeric value must always be interpreted alongside the patient's overall clinical condition and local oxygen protocols.
When delivering passive oxygen, selecting the proper delivery device and flow rate is essential. A nasal cannula delivers supplemental oxygen at a flow rate of 1 to 6 liters per minute and is suitable for patients with mild to moderate hypoxemia. When higher oxygen concentrations are necessary, a nonrebreather mask requires an oxygen flow rate of 10 to 15 liters per minute to keep the reservoir bag inflated. For most acutely ill patients who need supplemental oxygen, a common target oxygen saturation is 94% to 98%, subject to local protocol. For patients with chronic obstructive pulmonary disease who are at risk of retaining carbon dioxide, local protocol may specify an oxygen saturation target of 88% to 92%. However, an emergency medical technician must never withhold oxygen from any patient in severe respiratory distress or failure.
When positive-pressure ventilation is required for an adult with a pulse, deliver one breath about every 6 seconds. If the patient is in cardiac arrest, the rescuer must follow the applicable cardiopulmonary resuscitation protocol instead. Each artificial ventilation must be delivered steadily over one second to produce visible chest rise. Squeezing the bag too forcefully or too rapidly can have devastating consequences. Excessive ventilation rates or volumes can increase intrathoracic pressure and decrease venous return to the heart. This excessive positive-pressure ventilation can reduce cardiac output and significantly increase the risk of forcing air into the stomach, causing gastric distention and aspiration.
Pathophysiology and Assessment of Asthma and COPD
Asthma is a chronic inflammatory disorder characterized by bronchospasm, airway edema, and mucus plugging. When an individual with asthma encounters a trigger, the lower airways constrict and swell while secreting thick mucus. Common triggers for asthma exacerbations include allergens, cold air, exercise, smoke, and respiratory infections. This narrowing leads to air trapping in the alveoli, resulting in a prolonged expiratory phase as the patient struggles to push air out through the restricted passages.
A classic sign of asthma is wheezing, which is a high-pitched, musical sound caused by turbulent airflow through constricted lower airways. It is vital to distinguish this lower airway sound from stridor, which indicates upper airway obstruction. In a severe asthma exacerbation, the inability to speak in full sentences indicates severe respiratory compromise. If airflow becomes critically reduced, wheezing may disappear entirely; a silent chest in a patient with a severe asthma exacerbation can indicate critically reduced airflow and impending respiratory failure.
Chronic obstructive pulmonary disease consists primarily of emphysema and chronic bronchitis, two distinct disease processes that frequently overlap. Emphysema involves the destruction of alveolar walls and a loss of lung tissue elasticity. Because their lungs lose the elastic recoil needed to expel air, patients with emphysema frequently use pursed-lip breathing to create positive end-expiratory pressure and prevent small airway collapse. Over time, chronic air trapping and hyperinflation increase the chest's front-to-back diameter, producing a barrel-shaped chest. In contrast, chronic bronchitis is characterized by chronic inflammation and excessive mucus production in the bronchial tree. Auscultation of a patient with chronic bronchitis often reveals rhonchi, which are low-pitched, coarse rattling sounds caused by secretions in the large lower airways.
Patient Positioning, Breath Sounds, and Continuous Positive Airway Pressure
Patient positioning plays a major mechanical role in easing the work of breathing. Patients experiencing severe dyspnea often adopt the tripod position, leaning forward with hands resting on their knees or a table, which allows them to recruit accessory muscles to assist with breathing. Conscious patients experiencing dyspnea should typically be transported in a position of comfort, such as a seated or Fowler position, to maximize lung expansion. During assessment, the emergency medical technician should compare breath sounds on both sides of the chest at multiple locations when feasible, without delaying urgent treatment or transport.
When authorized by local protocol, continuous positive airway pressure is an effective non-invasive intervention for a conscious, cooperative patient who is breathing spontaneously and has significant respiratory distress, such as from chronic obstructive pulmonary disease or pulmonary edema; its use for asthma depends on local protocol. Continuous positive airway pressure helps keep alveoli open, improves oxygenation, and can help patients with pulmonary edema breathe more effectively. To receive continuous positive airway pressure, patients must be alert and capable of following verbal commands.
Because continuous positive airway pressure delivers continuous pressure to the respiratory circuit, it carries strict contraindications and physiological risks. Continuous positive airway pressure is contraindicated in patients in respiratory arrest or with agonal respirations, as these individuals lack adequate spontaneous breathing and require bag-valve-mask ventilation. It is also contraindicated in patients with hypotension or a systolic blood pressure below protocol thresholds, as well as those experiencing active vomiting or facial trauma. Emergency medical technicians must closely monitor blood pressure during therapy because continuous positive airway pressure can lower systemic blood pressure by increasing intrathoracic pressure and impeding venous return.
Assisting with Prescribed Metered-Dose Inhalers and Ongoing Reassessment
When an individual experiences bronchospasm from asthma or chronic obstructive pulmonary disease, an emergency medical technician may assist the patient with their prescribed metered-dose inhaler under medical direction or local protocol. A common medication prescribed for this purpose is albuterol. Albuterol is a beta-2 adrenergic agonist that relaxes bronchial smooth muscle to produce bronchodilation. Prior to administering any prescribed respiratory medication, the emergency medical technician must confirm the five rights of medication administration to ensure patient safety. Using a spacer with a metered-dose inhaler improves medication delivery to the lower respiratory tract, ensuring that more medication reaches the constricted bronchioles rather than impacting the back of the throat.
Assisting with an inhaler is subject to strict contraindications. Contraindications to assisting with a metered-dose inhaler include an unresponsive patient, an expired medication, or the medication not being prescribed to that patient. Even when appropriately administered, beta-2 agonists stimulate the sympathetic nervous system; common side effects of beta-2 agonists include tachycardia, tremors, anxiety, and palpitations. The emergency medical technician must explain these anticipated side effects to the patient to help reduce anxiety during treatment.
Managing respiratory emergencies requires vigilant, continuous monitoring. Ongoing reassessment of a respiratory emergency must evaluate the patient's work of breathing, mental status, respiratory rate, and breath sounds. Changes in any of these parameters can reveal whether the patient is improving under therapy or slipping from compensatory distress into decompensated respiratory failure. Any deterioration in mental status, tidal volume, or heart rate demands immediate reassessment and escalation of care; begin assisted ventilation if breathing is absent or inadequate.
Common mistakes
- Assuming that a patient with a rapid respiratory rate is breathing adequately, while failing to assess tidal volume (shallow chest rise indicates inadequate ventilation regardless of rate).
- Withholding high-flow oxygen from a chronic obstructive pulmonary disease patient who is in severe respiratory distress or respiratory failure out of fear of suppressing their respiratory drive.
- Mistaking a 'silent chest' in an asthma patient for clinical improvement rather than recognizing it as a sign of critically reduced airflow and impending respiratory failure.
- Applying continuous positive airway pressure to a patient who is lethargic, unable to follow commands, hypotensive, or experiencing agonal respirations.
Summary
- Respiratory distress involves increased work of breathing with initially preserved ventilation, whereas respiratory failure occurs when the body cannot maintain oxygenation or eliminate carbon dioxide.
- Inadequate tidal volume is identified by shallow chest rise and requires immediate bag-valve-mask ventilation delivering one breath every 6 seconds for an adult with a pulse.
- Avoid excessive ventilation rates and volumes because positive pressure increases intrathoracic pressure, decreases venous return, reduces cardiac output, and causes gastric distention.
- Asthma involves bronchospasm, edema, and mucus plugging leading to air trapping, prolonged expiration, and wheezing; a silent chest indicates critically reduced airflow and impending failure.
- Chronic obstructive pulmonary disease includes emphysema (loss of alveolar elasticity, barrel chest, pursed-lip breathing) and chronic bronchitis (inflammation, mucus, rhonchi).
- Continuous positive airway pressure keeps alveoli open in alert, spontaneously breathing patients with distress from pulmonary edema or COPD, but is contraindicated in arrest, vomiting, facial trauma, or hypotension.
- Under medical direction or protocol, an EMT may assist an alert patient with their prescribed albuterol inhaler after confirming the five rights, utilizing a spacer to improve delivery.
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