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Chapter 17
Respiratory Emergencies
Slide 1
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Case History
A 30-year-old male walks into your
headquarters complaining of severe
difficulty in breathing. The patient’s wife
tells you that this started about 2 hours
ago. He tells you that he has asthma
and is carrying a metered-dose inhaler.
Slide 2
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Respiratory System
Slide 3
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Upper Respiratory Tract
Slide 4
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Lower Respiratory Tract
Slide 5
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Muscles of Respiration
Slide 6
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Inspiration (Active Process)
• Diaphragm flattens, increases inferior-superior
diameter of chest.
• External intercostals pull ribs up, increase anteriorposterior, lateral dimensions.
• Chest cavity increases in size – more volume, less
gas, decrease in pressure, air rushes in
• Inspiration continues until pressure between lung and
atmosphere equalizes.
Slide 7
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Expiration (Passive Process)
• Elastic recoil of lungs plus muscle relaxation
• Chest cavity decreases in size – less volume,
more gas, air rushes out to atmosphere.
• Expiration continues until atmosphere and
chest pressure are equal.
Slide 8
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Inspiration and Expiration
Slide 9
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Diffusion of Oxygen and
Carbon Dioxide
Slide 10
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Pathophysiology –
Airway Obstruction
• Obstruction by the
tongue
 Unconsciousness
 Relaxed jaw and epiglottis
 Obstruction of the
pharynx
 Evidenced by snoring
 Cleared with manual
maneuvers and adjuncts
Slide 11
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Pathophysiology –
Airway Obstruction
• Swollen epiglottis and other airway structures
 Epiglottitis and anaphylaxis
 Obstruction at or above the vocal cords
 Evidenced by stridor or crowing
 Surgical airway may be needed
 Positive-pressure ventilation can be lifesaving.
Slide 12
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Pathophysiology –
Airway Obstruction
• Fluid in airway
 Aspiration, pulmonary edema, or drowning
 Evidenced by gurgling
 Immediate suctioning of the airway is critical.
Slide 13
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Anatomy Considerations –
Infants and Children
• Smaller airways
• Tongue is larger in relation to mouth.
• Trachea
 Narrower
 More pliable
• Cricoid cartilage
 Smaller and less rigid
 Narrowest portion of the airway
• Infants and children depend on
diaphragm for breathing.
Slide 14
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Problems Associated with
Respiratory Patients
• Difficulty breathing
• Inadequate
breathing
(respiratory failure)
• Respiratory arrest
Slide 15
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Adequate Breathing – Rate
• Adult: 12-20/min
• Child: 15-30/min
• Infant: 25-50/min
Slide 16
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Adequate Breathing
• Rhythm
 Regular
 Irregular
• Quality
 Breath sounds – present and
equal
 Chest expansion – adequate
and equal
 Minimum effort of breathing
• Depth (tidal volume) –
adequate
Slide 17
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Signs of Inadequate Breathing
• Very slow respiratory rate
• Very rapid respiratory rate
• Shallow breathing
• Diminished or absent
breaths sounds
Slide 18
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Signs of Inadequate Breathing
• Altered level of
consciousness
• Seesaw breathing (infants
and children)
• Pale or cyanotic skin color
• Cool and clammy skin
Slide 19
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Increased Work of Breathing
• Accessory muscle use
• Retractions
• Nasal flaring
• Sitting upright
• Tripod position
Slide 20
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Inadequate Breathing
• Rate – outside of normal ranges
• Rhythm – irregular
• Quality
 Breath sounds – diminished or absent
 Chest expansion – unequal or inadequate
 Increased effort of breathing – use of accessory muscles –
predominantly in infants and children
• Depth (tidal volume) – inadequate/shallow
Slide 21
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Adequate Ventilation
• Chest rises and falls with
each artificial ventilation.
• Rate
 Adults – 12/min
 Infants and children – 20/min
• Heart rate returns to
normal.
Slide 22
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Inadequate Ventilation
• The chest does not rise
and fall with artificial
ventilation.
• The rate is too slow or
too fast.
• Heart rate does not
return to normal with
artificial ventilation.
Slide 23
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Assessing the Patient with
Difficulty Breathing
Slide 24
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Scene Size-up
• Scene safety
• If trauma
 Consider mechanism of injury.
 Provide spinal immobilization.
• Be alert for toxic environment.
• Body substance isolation
 If fluids are present in airway, consider need
for eyewear, gowns, gloves, and mask.
 If TB is possible, consider need for HEPA
respirator.
Slide 25
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Initial Assessment –
General Impression
• Is there obvious life threat, such as respiratory arrest?
• In what position is patient found?
 Bolt upright? Tripod?
 Sleepy or unresponsive?
» May require positive-pressure ventilation
• Does patient speak in complete sentences?
• Other obvious signs of respiratory distress?
Slide 26
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Initial Assessment – Airway
• Signs of obstruction?
 Inability to speak
 Universal choking sign
• Sounds associated with
obstruction
 Noisy breathing
 Crowing or stridor (upper airway)
 Gurgling (fluids)
 Snoring (tongue)
 Audible wheezing (lower airway)
Slide 27
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Initial Assessment –
Airway Management
• Manual maneuvers
 Head tilt/ chin lift
 Jaw thrust
• Use of adjuncts
 Nasopharyngeal airway
 Oropharyngeal airway
• FBAO maneuvers
• Suctioning
• Assistance with MDI medication
(bronchiole constriction)
Slide 28
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Initial Assessment – Breathing
• Decrease in tidal volume or rate (minute volume)
 Tidal volume  rate = minute volume
» Examples:
o
o
o
Normal: 500 mL/breath  12 breaths/min = 6000 mL
Hypoventilation: 200 mL/breath  12 breaths/min = 2400 mL
Hypoventilation: 500 mL  6 breaths/min = 3000 mL
• Critical to evaluate
 Tidal volume (chest rise)
 Respiratory rate
 Other signs of hypoxia
» Mental state
» Skin color
Slide 29
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Signs and Symptoms of
Difficulty Breathing
• Shortness of breath
• Restlessness
• Increased pulse rate
Slide 30
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Signs and Symptoms of
Difficulty Breathing
• Pale or cyanotic skin
• Coughing
• Tripod position
Slide 31
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Signs and Symptoms of
Difficulty Breathing
• Shortness of breath
• Restlessness
• Increased breathing rate
• Decreased breathing rate
Slide 32
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Skin Color Changes
• Cyanotic (blue-gray)
• Pale
• Flushed (red)
Slide 33
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Signs and Symptoms of
Difficulty Breathing
• Inability to speak because of breathing efforts
• Retractions – use of accessory muscles
• Shallow or slow breathing
 May lead to altered mental status with fatigue or
obstruction
• Abdominal breathing (diaphragm only)
Slide 34
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Signs and Symptoms of
Difficulty Breathing
• Coughing
• Irregular breathing pattern
• Patient position
 Tripod position (sitting with feet dangling, leaning
forward)
• Unusual anatomy (barrel chest)
Slide 35
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Important Questions
•
•
•
•
•
•
•
Onset
Provocation
Quality
Radiation
Severity
Time
Interventions
Slide 36
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Primary Management of
Respiratory Emergencies
• Airway management
• Positive-pressure ventilation
• Supplemental oxygen
• Positioning
• Administration of prescribed
inhalers
Breathing
• Complains of trouble breathing
 Apply oxygen, if not already done.
 Assess baseline vital signs.
• Has a prescribed inhaler available
 Consult medical direction.
 Facilitate administration of inhaler.
Slide 38
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Breathing
• Does not have prescribed inhaler
 Continue with focused assessment.
• Be prepared to intervene with
appropriate oxygen administration.
 Positive-pressure ventilation (if patient
will tolerate)
Slide 39
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Prescribed Inhaler
• Generic name
 Albuterol, isoetharine,
metaproterenol, etc.
• Trade name
 Proventil, Ventolin, Bronkosol,
Bronkometer, Alupent,
Metaprel, etc.
Slide 40
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Prescribed Inhaler –
Indications
• Exhibits signs and symptoms of respiratory
emergency
• Has physician prescribed handheld inhaler?
• Specific authorization by medical direction
Slide 41
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Prescribed Inhaler –
Contraindications
• Inability of patient to use device
• Inhaler is not prescribed for the patient
• No permission from medical direction
• Patient has already met maximum prescribed
dose before EMT arrival.
Slide 42
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Administration of Inhaler
• Check the expiration date.
• Check to see if the patient has already taken
any doses.
• Ensure that the inhaler is at room temperature
or warmer.
• Shake the inhaler vigorously several times.
• Remove oxygen adjunct from patient.
• Have the patient exhale deeply.
Slide 43
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Administration of Inhaler
• Replace oxygen adjunct on patient.
• Allow patient to breathe a few times.
 Repeat second dose per medical direction.
• If patient has a spacer device, it should be
used for more effective results.
Slide 44
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Actions of Inhaler
• Beta-agonist
• Dilates bronchioles
• Reduces airway resistance
Slide 45
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Reassessment Strategies
• Gather vital signs.
• Perform focused reassessment.
 Patient’s condition may deteriorate.
» Consider need for positive-pressure artificial
ventilation.
Slide 46
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Side Effects of Inhaler
• Increased pulse rate
• Tremors
• Nervousness
Slide 47
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Infant and Child
Considerations
• Use of handheld inhalers is very common in children.
• Retractions are more common in children.
• Cyanosis is a late finding in children.
• Coughing rather than wheezing may be present in
some children.
• Use of inhalers is the same if the indications are met
by the ill child.
Slide 48
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Causes of
Respiratory Emergencies
• Chronic obstructive pulmonary disease
• Asthma
• Pneumonia
• Hyperventilation syndrome
• Spontaneous pneumothorax
Slide 49
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Chronic Obstructive
Pulmonary Disease (COPD)
• Chronic respiratory condition
 Chronic bronchitis
 Emphysema
• Primary complaint – dyspnea
 Bronchoconstriction
Slide 50
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Chronic Bronchitis
• Chronic productive cough for > 3 mo/yr x 2 yrs
• Caused by smoking or long-term exposure to
environmental pollutants
Slide 51
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Chronic Bronchitis
Bronchial obstruction = poorly ventilated
alveoli = poorly oxygenated blood = cyanosis
 “Blue bloater”
Slide 52
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Chronic Bronchitis
• Signs
 Cyanosis
 Edema – ankles, hips, abdomen
» Result of right-sided heart failure
 Jugular venous distention
 Wheezing, possible crackles
Slide 53
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Emphysema
• Caused by destruction of alveoli
• Less lung surface for oxygen to diffuse into blood
• Small bronchioles damaged also
 Collapse on exhalation = air trapped in lungs
» Barrel chest
» Pursed lips
• Body may increase red blood cells and hemoglobin
 “Pink puffer”
Slide 54
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COPD
• Signs
 Can only walk short distances
 Home oxygen
Slide 55
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COPD
• Normal regulation for breathing – carbon dioxide
• Patients with COPD retain high levels of carbon
dioxide.
 Regulation for breathing – low oxygen levels
• Supplemental oxygen may turn hypoxic drive off,
resulting in hypoventilation or respiratory arrest.
 Be alert.
Slide 56
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COPD
Do not withhold oxygen for COPD
patients in shock, with altered mental
status, or in severe respiratory arrest.
Prepare to assist ventilations.
Slide 57
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Asthma
• Caused by constriction of the lower airways
 Triggered by stress, infection, or allergy
• Signs
 Dyspnea
 Upright posture
 Possible accessory muscle use
 Flushing
 Forceful breathing
 Audible wheezing
 Fatigue
 Respiratory failure
Slide 58
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Pneumonia
• Inflammation of alveolar spaces
 Interferes with normal exchange of oxygen with
blood
• Signs and symptoms
 Depend on underlying cause
» Dyspnea
» Fever
» Cough
» Sputum production
» Crackles or diminished breath sounds
Slide 59
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Hyperventilation Syndrome
• Increase in rate and depth of breathing = decreased
amount of carbon dioxide
 Result: tingling around mouth and fingers, dizziness,
possible nausea
 Often result of anxiety
• Check for underlying causes
 Asthma, COPD
• If no other known cause, administer oxygen, and
calm reassurance.
Slide 60
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Spontaneous Pneumothorax
• Rupture of part of the lung
 Allows air to exit the lung into the pleural space
 Lung may partially or totally collapse
• Frequently seen in thin, muscular men
Slide 61
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Spontaneous Pneumothorax
• Signs
 Sudden onset of dyspnea and pleuritic chest pain
 Diminished breath sounds on one side
• Monitor patient for progression to tension
pneumothorax
 Absent breath sounds on one side
 Distended neck veins
 Hypotension
 Tracheal deviation
Slide 62
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Croup and Epiglottitis
• Usually occurs in children
 Epiglottitis can occur in adults.
• Croup – viral infection that causes swelling
and narrowing of the upper airway (below
thyroid cartilage)
• Epiglottitis – bacterial infection that causes
swelling of the epiglottis
Slide 63
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Croup and Epiglottitis
• Signs
 Fever
 Dyspnea
 Coughing
 Stridor or crowing
 Increased work of breathing
 Tripod position
Slide 64
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