Respiratory Emergencies
Chapter 16
Objectives
- List the structure and function of the respiratory system.
- State the signs and symptoms of a patient with breathing difficulty.
- Describe the emergency medical care of the patient with breathing difficulty.
- Recognize the need for medical direction to assist in the emergency medical care of the patient
with breathing difficulty.
- Describe the emergency medical care of the patient with breathing distress.
- Establish the relationship between airway management and the patient with breathing difficulty.
- List signs of adequate air exchange.
- State the generic name, medication forms, dose, administration, action, indications and
contraindications for the prescribed inhaler.
- Distinguish between the emergency medical care of the infant, child and adult patient with
breathing difficulty.
- Differentiate between upper airway obstruction and lower airway disease in the infant and child
patient.
- Defend EMT-Basic treatment regimens for various respiratory emergencies.
- Explain the rationale for administering an inhaler.
I. Anatomy review
A. Respiratory
1. Nose and mouth
2. Pharynx
a. Oropharynx
b. Nasopharynx
3. Epiglottis - a leaf-shaped structure that prevents food and liquid
from entering the trachea during swallowing.
4. Trachea (windpipe)
5. Cricoid cartilage - firm cartilage ring forming the lower portion of
the larynx.
6. Larynx (voice box)
7. Bronchi - two major branches of the trachea to the lungs.
Bronchus subdivides into smaller air passages ending at the
alveoli.
8. Lungs
9. Diaphragm
a. Inhalation (active)
(1) Diaphragm and intercostal muscles contract,
increasing the size of the thoracic cavity.
(a) Diaphragm moves slightly downward, flares
lower portion of rib cage.
(b) Ribs move upward/outward.
(2) Air flows into the lungs.
b. Exhalation
(1) Diaphragm and intercostal muscles relax,
decreasing the size of the thoracic cavity.
(a) Diaphragm moves upward.
(b) Ribs move downward/inward.
(2) Air flows out of the lungs.
10. Respiratory physiology
a. Alveolar/capillary exchange
(1) Oxygen-rich air enters the alveoli during each
inspiration.
(2) Oxygen-poor blood in the capillaries passes into
the alveoli.
(3) Oxygen enters the capillaries as carbon dioxide
enters the alveoli.
b. Capillary/cellular exchange
(1) Cells give up carbon dioxide to the capillaries.
(2) Capillaries give up oxygen to the cells.
c. Adequate breathing
(1) Normal Rate
(a) Adult - 12-20/minute
(b) Child - 15-30/minute
(c) Infant - 25-50/minute
(2) Rhythm
(a) Regular
(b) Irregular
(3) Quality
(a) Breath sounds - present and equal
(b) Chest expansion - adequate and equal
(c) Effort of breathing - use of accessory
muscles - predominantly in infants and children
(4) Depth (tidal volume) - adequate
d. Inadequate breathing
(1) Rate - outside of normal ranges.
(2) Rhythm - irregular
(3) Quality
(a) Breath sounds - diminished or absent
(b) Chest expansion - unequal or inadequate
(c) Increased effort of breathing - use of
accessory muscles - predominantly in infants
and children
(4) Depth (tidal volume) - inadequate/shallow
(5) The skin may be pale or cyanotic (blue) and cool
and clammy.
(6) There may be retractions above the clavicles,
between the ribs and below the rib cage, especially in
children.
(7) Nasal flaring may be present, especially in
children.
(8) In infants, there may be "seesaw" breathing where
the abdomen and chest move in opposite directions.
(9) Agonal breathing (occasional gasping breaths)
may be seen just before death.
11. Infant and child anatomy considerations
a. Mouth and nose - in general: All structures are smaller
and more easily obstructed than in adults.
b. Pharynx - infants' and children's tongues take up
proportionally more space in the mouth than adults.
c. Trachea (windpipe)
(1) Infants and children have narrower tracheas that
are obstructed more easily by swelling.
(2) The trachea is softer and more flexible in infants
and children.
d. Cricoid cartilage - like other cartilage in the infant and
child, the cricoid cartilage is less developed and less rigid.
e. Diaphragm - chest wall is softer, infants and children tend
to depend more heavily on the diaphragm for breathing.
B. Adequate and inadequate artificial ventilation
1. An EMT-Basic is adequately artificially ventilating a patient when:
a. The chest rises and falls with each artificial ventilation.
b. The rate is sufficient, approximately 12 per minute for
adults and 20 times per minute for children and infants.
c. Heart rate returns to normal with successful artificial
ventilation.
2. Artificial ventilation is inadequate when:
a. The chest does not rise and fall with artificial ventilation.
b. The rate is too slow or too fast.
c. Heart rate does not return to normal with artificial
ventilation.
II. Breathing Difficulty
A. Signs and symptoms
1. Shortness of breath
2. Restlessness
3. Increased pulse rate
4. Increased breathing rate
5. Decreased breathing rate
6. Skin color changes
a. Cyanotic (blue-gray)
b. Pale
c. Flushed (red)
7. Noisy breathing
a. Crowing
b. Audible wheezing
c. Gurgling
d. Snoring
e. Stridor
(1) A harsh sound heard during breathing
(2) Upper airway obstruction
8. Inability to speak due to breathing efforts.
9. Retractions - use of accessory muscles.
10. Shallow or slow breathing may lead to altered mental status
(with fatigue or obstruction).
11. Abdominal breathing (diaphragm only)
12. Coughing
13. Irregular breathing rhythm
14. Patient position
a. Tripod position
b. Sitting with feet dangling, leaning forward.
15. Unusual anatomy (barrel chest)
III. Emergency Medical Care - Focused History and Physical Exam
A. Important questions to ask
1. Onset
2. Provocation
3. Quality
4. Radiation
5. Severity
6. Time
7. Interventions
B. Breathing
1. Complains of trouble breathing.
a. Apply oxygen if not already done.
b. Assess baseline vital signs.
2. Has a prescribed inhaler available.
a. Consult medical direction.
b. Facilitate administration of inhaler
(1) Repeat as indicated.
(2) Continue focused assessment.
3. Does not have prescribed inhaler - continue with focused
assessment.
IV. Relationship to Airway Management - should be prepared to intervene with
appropriate oxygen administration and artificial ventilation support.
V. Lung Disease
A. Causes of Lung Disease
1. Obstruction of pulmonary vessels by fluid, infection, or collapsed
air spaces
2. Damaged alveoli
3. Obstructed air passages by muscle spasm, mucous, or
weakened floppy airway walls
4. Obstruction of blood flow by clots
5. Lungs are unable to expand due to fluid/air in the pleural space
B. Respiratory Drive
1. Normal Respiratory Drive
a. Brain stem is sensitive to CO2 levels in the arterial
blood
b. Increased CO2 causes an increase in respiratory
rate/depth
c. Decreased CO2 causes a decrease in respiratory
rate/depth
2. Hypoxic Drive
a. Brain stem becomes sensitive to O2 levels in the
arterial blood
b. Decreased O2 causes an increase in respiratory
rate/depth
c. Increased O2 causes a decrease in respiratory
rate/depth
d. Giving too much O2 to these patients may cause
respirations to become depressed or stop
C. NEVER WITHOLD OXYGEN FROM A PATIENT THAT IS HYPOXIC
VI. Causes of Dyspnea
A. Upper or Lower Airway Infection
1. May cause swelling of tissues which obstructs the air flow into
the lungs (colds, epiglottitis, croup)
2. May cause exchange of O2 and CO2 at the alveolar/capillary
level to be obstructed due to fluid/mucous/damage (pneumonia)
3. Epiglottitis
a. Severe swelling of the epiglottis
b. Normally seen in children but can occur in adults
c. May be sudden in onset
d. Usually accompanied by a high fever
e. Patient may have stridor or will be drooling
f. Do not attempt to visualize or place anything into the
airway
g. Treat with supplemental O2 without agitating the patient
h. Transport in position of comfort (usually sniffing
position)
4. Croup
a. Causes swelling of the lining of the larynx
b. Normally seen in children up to 3 years old
c. Seal-like barking cough
d. Treat with supplemental O2, humidified if possible
e. Transport in position of comfort
5. Pneumonia
a. Acute inflammation of the alveoli
b. Treatment is supportive, O2 as needed
B. Acute Pulmonary Edema
1. Causes
a. Weakened left side of the heart due to heart attack (MI)
or other illness
2. Physiology
a. Heart cannot pump blood out as fast as it receives it
b. Fluid backs up into the lungs
c. Fluid separates alveoli/capillary beds
d. Decreases available space in lungs for air movement
and blood flow
e. Can be rapid or delayed in onset
3. Assessment Findings
a. Dyspnea
b. Normal to increased blood pressure
c. Tachycardia
d. Lung sounds – Rales
4. Treatment
a. High flow O2, consider BVM
b. Suction as needed
c. Transport in position of comfort
5. Traumatic Pulmonary Edema
a. Causes
(1) Inhalation of heated air, chemicals, toxic fumes, or
injury to the chest
b. Physiology
(1) Same as cardiac pulmonary edema except fluid is
caused by response to damaged tissue
c. Assessment Finding and Treatment are the same as
cardiac etiology of pulmonary edema
C. COPD
1. Chronic Bronchitis
a. Causes
(1) Smoking
b. Physiology
(1) Constant production of excess mucous
(2) Mechanisms that remove foreign particles are
paralyzed
(3) Pneumonia develops easily
(4) Patient’s lose the ability to compensate for any
lung insult
c. Assessment Findings
(1) Somewhat obese (blue bloater)
(2) Frequent productive cough
(3) Pursed lip breathing
(4) Lung sounds – rhonchi
d. Treatment
(1) O2 as needed
(2) Assist patient with home meds (inhalers)
(3) Transport in position of comfort (usually sitting
upright)
2. Emphysema
a. Causes
(1) Smoking
b. Physiology
(1) Destruction of alveolar walls
(2) Alveoli lose the ability to recoil and expel air
(3) Large air pockets or dead space develops in the
lungs
(4) Patient’s lose the ability to compensate for any
lung insult
c. Assessment Findings
(1) Patient’s will usually be thin with a barrel chest
(2) Reddish/pink skin color (pink puffer)
(3) Tachypnea
(4) Accessory muscle use
(5) Pursed lip breathing
(6) Lung sounds – Decreased and/or wheezes
d. Treatment
(1) O2 as needed
(2) Assist patient with home meds (inhalers)
(3) Transport in position of comfort (usually sitting
upright)
D. Spontaneous Pneumothorax
1. Causes
a. Chronic lung infections or people with weak lungs
(asthma, emphysema)
b. Coughing spell
2. Physiology
a. Air leaks into pleural space causing lung to partially
collapse
3. Assessment Findings
a. Sharp, stabbing, one sided chest pain which is worse
with inspiration
b. Dyspnea
c. Lung sounds – Decreased or normal
d. Can be extremely difficult to detect
4. Treatment
a. Reassess often
b. O2 as needed
c. Transport in position of comfort
E. Asthma
1. Triggers
a. Allergies
b. Infections
c. Stress
d. Exercise
e. Cold air
f. Aspiration
2. Physiology
a. Bronchi and bronchiole smooth muscle spasm
b. Increased mucous production
c. Bronchiole inflammation
3. Assessment Findings
a. Dyspnea (the faster the onset the more serious the
situation)
b. Persistent cough
c. Tachypnea
d. Accessory muscle use
e. Speaking in short sentences
f. Lung sounds – Wheezes with expiration or silent chest
4. Treatment
a. High flow O2
b. Assist patient with medications (inhalers, Epi- pen)
c. Keep patient calm
d. Position of comfort
F. Allergic Reactions (Anaphylaxis)
1. Causes
a. Allergic reaction (bee sting, peanuts etc.)
2. Physiology
a. Body overreacts to the allergen causing vasodilation
and bronchoconstriction
3. Assessment Findings
a. Same as with asthma
b. Decreased blood pressure
c. Itching and hives
4. Treatment
a. Same as asthma
b. Rapid Transport
G. Pleural Effusions
1. A collection of fluid outside the lung on one or both sides of the
chest which may compress the lung or lungs
2. Treat supportive as needed
H. Pulmonary Embolus
1. Causes
a. Damage to the lining of vessels
b. Slow blood flow in a lower extremity (prolonged bed
rest)
c. Recent surgeries
d. Birth control pills
e. Smoking
f. Recent Fractures
2. Physiology
a. Blood clot travels to the lung via the venous system
usually from a lower extremity
b. Decreases or blocks blood flow to the lung beyond the
clot
3. Assessment Findings
a. Dyspnea
b. Chest pain (usually sharp)
c. Tachypnea
d. Tachycardia
e. Coughing up blood tinged sputum
4. Treatment
a. High flow O2
b. Position of comfort
I. Hyperventilation Syndrome
1. Causes / Patient Characteristics
a. Stress/anxiety
b. Young females
2. Physiology
a. Patient blows off too much CO2
3. Assessment Findings
a. Dyspnea
b. Chest pain (usually sharp)
c. Tachypnea
d. Tachycardia
e. Numbness/tingling around mouth/hands
f. Presents the same as pulmonary embolus except for
carpal pedal spasms (muscle spasms of fingers/toes)
4. Treatment
a. Calm the patient
b. Treat for P.E. if not absolutely sure
c. Never place a mask over patients face without O2 or
have them breathe into a paper bag
d. Remove them from stressful environment
VII. Medications
A. Prescribed inhaler
1. Medication name
a. Generic - albuterol, isoetharine, metaproteranol, etc.
b. Trade - Proventil, Ventolin, Bronkosol, Bronkometer,
Alupent, Metaprel, etc.
2. Indications - meets all of the following criteria:
a. Exhibits signs and symptoms of respiratory emergency,
b. Has physician prescribed handheld inhaler, and
c. Specific authorization by medical direction.
3. Contraindications
a. Inability of patient to use device.
b. Inhaler is not prescribed for the patient.
c. No permission from medical direction.
d. Patient has already met maximum prescribed dose prior
to EMT-Basic arrival.
4. Medication form - handheld metered dose inhaler
5. Dosage - number of inhalations based upon medical direction's
order or physician's order based upon consultation with the patient.
6. Administration
a. Obtain order from medical direction either on-line or offline.
b. Assure right medication, right patient, right route, patient
alert enough to use inhaler.
c. Check the expiration date of the inhaler.
d. Check to see if the patient has already taken any doses.
e. Assure the inhaler is at room temperature or warmer.
f. Shake the inhaler vigorously several times.
g. Remove oxygen adjunct from patient.
h. Have the patient exhale deeply.
i. Have the patient put his lips around the opening of the
inhaler.
j. Have the patient depress the handheld inhaler as he
begins to inhale deeply.
k. Instruct the patient to hold his breath for as long as he
comfortably can (so medication can be absorbed).
l. Replace oxygen on patient.
m. Allow patient to breathe a few times and repeat second
dose per medical direction.
n. If patient has a spacer device for use with his inhaler, it
should be used. A spacer device is an attachment between
inhaler and patient that allows for more effective use of
medication.
7. Actions - Beta agonist bronchodilators - dilates bronchioles
reducing airway resistance.
8. Side effects
a. Increased pulse rate
b. Tremors
c. Nervousness
9. Re-assessment strategies
a. Gather vital signs and focused reassessment.
b. Patient may deteriorate and need positive pressure
artificial ventilation.
10. Infant and child considerations
a. Use of handheld inhalers is very common in children.
b. Retractions are more commonly seen in children than
adults.
c. Cyanosis (blue-gray) is a late finding in children.
d. Very frequent coughing may be present rather than
wheezing in some children.
e. Emergency care with usage of handheld inhalers is the
same if the indications for usage of inhalers are met by the ill
child.