RESPIRATORY EMERGENCIES
GENERAL CONSIDERATIONS
A. There are a number of different treatments for respiratory distress depending on the cause.
Some of these interventions can be dangerous if given to the wrong person. It is therefore
important to try to determine the cause as accurately as possible.
B. This protocol includes management of the following respiratory emergencies:
1. Apneic patient
2. Airway obstruction
3. Wheezing
4. Rales / pulmonary edema
C. General assessment and management of all patients in respiratory distress should include:
1. Assess and manage airway:
a. Administer oxygen as needed to treat shock and/or respiratory distress
b. Apply pulse oximeter and treat per pulse oximeter procedure
c. Be prepared to assist ventilations
2. Evaluate patient’s general appearance, relevant history of condition and determine
OPQRSTI and SAMPLE. Especially ask about the severity of the patient’s
underlying disease. When was the last time they seen by a doctor or hospitalized for
this? Ever intubated? Ask about medication compliance.
3. Try to obtain patient’s resuscitation status (i.e., DNR Comfort Care or DNR Comfort
Care Arrest). Intubation is an aggressive treatment and may be against the patient’s
wishes.
4. Auscultate lung fields anteriorly, comparing side-to-side, and posteriorly when
possible. (i.e., patient is able to sit up)
5. Allow patient to assume position of comfort
6. Contact Medical Control, advise of patient condition and TRANSPORT immediately
unless an ALS unit is en route with an ETA < 5 minutes.
APNEIC PATIENT
Basic EMT
A. Patient’s airway is open, breathing absent, pulse present: Provide positive-pressure
ventilations with 100% oxygen. Each breath is delivered over one second with enough
volume to cause chest rise
1. Pediatric rate: one breath every 3-5 seconds
2. Adult rate: one breath every 5-6 seconds
Advanced EMT / Paramedic
A. Secure airway. Refer to Advanced Airway Procedures.
B. Place patient on cardiac monitor
C. Start IV normal saline, TKO
D. Transport
Effective 9/3/15
Replaces 7/1/11
Respiratory Emergencies
Page 1 of 4
OBSTRUCTED AIRWAY
Basic & Advanced EMT
A. Foreign body obstruction; patient able to speak / cough:
1. Reassure patient
2. Allow patient to attempt clearing airway by self
B. Foreign body obstruction; patient unable to cough / speak, airway obstructed:
1. Adult / Child > 1 year old: Deliver abdomen / chest thrusts. Repeat until effective or
patient becomes unresponsive
2. Infant (< 1 year of age): Deliver series of five backblows and five chest thrusts.
Repeat until effective or patient becomes unresponsive
3. If patient becomes unresponsive, begin CPR per current AHA guidelines. Look in
mouth when opening airway during CPR. Use finger sweeps ONLY to remove visible
foreign body.
4. If airway cannot be cleared in 60 seconds, transport immediately to nearest
appropriate hospital
C. Airway obstruction due to medical cause (epiglottitis, croup, anaphylaxis) treat underlying
cause
1. Croup (barking cough, stridor, retractions, typically between 6 months and 4 years
old, more prevalent in fall and winter): Keep patient upright, administer humidified
oxygen if available
2. Epiglottitis (sudden onset, drooling, sore throat, muffled voice, stridor): Transport
upright immediately. Do NOT agitate the child. Do NOT examine throat.
Advanced EMT
A. Suspected croup: consider epinephrine 1:1000 0.5 mg/kg (max 5mg or 5ml) administered by
nebulizer / aerosol.
Paramedic
A. Foreign body airway obstruction not relieved by manual maneuvers - try to visualize
obstruction with laryngoscope and remove foreign body with Magill forceps if possible
B. If airway cannot be cleared – perform a cricothyroidotomy (must contact Medical Control for
pediatric patients)
Effective 9/3/15
Replaces 7/1/11
Respiratory Emergencies
Page 2 of 4
WHEEZING
Basic EMT
A. If suspected allergic reaction / anaphylaxis, See Allergic Reaction / Anaphylactic Shock
Protocol
B. Consider CPAP for adult patients. See CPAP Procedure
C. May assist with prescribed metered-dose inhaler (MDI)
1. Assure that medication is prescribed for patient
2. Check medication – dose, expiration date
3. Administer MDI by having patient exhale, then activate device during inhalation and
patient hold breath so that medication can be absorbed.
Advanced EMT
A. Suspected asthma or bronchitis administer:
1. Duoneb (ipratropium bromide 0.5 mg and albuterol sulfate 3 mg in 3 ml) aerosol:
a. Adolescent and Adult Dose: 3ml by nebulizer / aerosol
b. Child Dose: 1.5 ml by nebulizer / aerosol
2. If additional treatments are required, administer albuterol aerosols prn
B. Suspected bronchiolitis (typically child < 2 years, history of RSV, nasal secretions, low-grade
temperature, frequently occurs in winter months) – consider epinephrine 1:1000 0.5 mg/kg
(max 5mg or 5ml) administered by nebulizer / aerosol.
Paramedic
A. Consider methylprednisolone (Solu-Medrol) :
1. Adult Dose: 125 mg Slow IVP
2. Pediatric Dose: 2 mg/kg Slow IVP
B. If patient condition continues to deteriorate, consider epinephrine, 1:1000
1. Adult Dose: 0.3 mg IM
2. Pediatric Dose: 0.01 mg/kg IM
Do not administer if patient is pregnant or has history of heart disease.
C. Intubate as indicated. Consider administering midazolam (Versed) prior to intubation. See
Procedural Sedation Protocol
Effective 9/3/15
Replaces 7/1/11
Respiratory Emergencies
Page 3 of 4
PULMOMARY EDEMA
Pulmonary edema is most commonly associated with acute myocardial infarction but it can also
result from pulmonary infections, inhaled toxins, narcotic overdose, pulmonary embolism, and
decreased atmospheric pressure. Acute pulmonary edema can develop rapidly in the elderly.
Pulmonary edema causes severe dyspnea associated with congestion. Other signs and
symptoms include:
• Rapid, labored breathing
• Cough with blood-stained sputum or pink, frothy sputum
• Cyanosis
• Moist crackles on auscultation of lung fields; severe cases may have rhonchi
• Accessory muscle use
Basic EMT
A. Consider CPAP for adult patients. See CPAP Procedure.
Advanced EMT
A. Obtain IV access – Normal Saline, TKO
B. Place on cardiac monitor
C. Administer Nitroglycerin 0.4 mg SL, one every 5 minutes to a maximum of 3 doses. HOLD if
SPB < 100 mmHg
Paramedic
A. Consider administering 2-5 mg morphine slow IVP or fentanyl 50-100 mcg slow IVP if patient
still in respiratory distress, anxious AND SBP remains > 100 mmHg
B. Intubate as indicated. Consider administering midazolam (Versed) prior to intubation. See
Procedural Sedation Protocol.
Effective 9/3/15
Replaces 7/1/11
Respiratory Emergencies
Page 4 of 4
KEY
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
APNEIC
PATIENTS
VOMITING
BASIC EMT
ADVANCED EMT
PARAMEDIC
MED CONTROL
















ASSESS
AIRWAY
OPEN AND
MANAGE AIRWAY
IF
AIRWAY
IS OPEN,
BREATHING IS ABSENT
MAINTAIN O2
SATS >95%
AND
A
PULSE
IS
PRESENT:
PROVIDE POSITIVEEVALUATE PATIENT CONDITION
PRESSURE VENTILATIONS WITH OXYGEN.
MONITOR VITAL SIGNS
DELIVER EACH BREATH OVER ONE SECOND
o HYPOPERFUSION (BP < 100 SYSTOLIC)
WITH ENOUGH VOLUME TO CAUSE CHEST RISE
OBTAIN MEDICAL HISTORY
Oo PEDIATRIC
RATE: ONE BREATH EVERY 3-5
NAUSEA/VOMITING
SECONDS
o SURGERY
Oo ADULT
RATE: ONE BREATH EVERY 5-6
TRAUMA
SECONDS
REASSURE PATIENT
MAINTAIN
O2 SATS
>95%
GIVE NOTHING
BY MOUTH
EVALUATE
PATIENT
CONDITION
TRANSPORT
IN POSTIION
OF COMFORT
OBTAIN MEDICAL HISTORY
o SEVERITY OF UNDERLYING DISEASE?
o EVER SEEN PHYSICIAN OR HOSPITALIZED
FOR THIS?
o HAS THE PATIENT EVER BEEN INTUBATED?
o MEDICATION COMPLIANCE?
o DNR STATUS?
MONITOR VITAL SIGNS
REASSURE PATIENT
TRANSPORT
SECURE
AIRWAY.
REFER TO
ADVANCED AIRWAY
IV NS (RUN
TO MAINTAIN
PERFUSION)
PROCEDURES.
MONITOR ECG
IV
NS (BOLUS
AS MANAGEMENT
NEEDED TO MAINTAIN
PERFUSION)
CONSIDER
PAIN
PROTOCOL
MONITOR ECG
P
E
D
I
A
T
R
I
C
S
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
APNEIC
PATIENTS
VOMITING
KEY
BASIC EMT
ADVANCED EMT
PARAMEDIC
MED CONTROL
















ASSESS
AIRWAY
OPEN AND
MANAGE AIRWAY
IF
AIRWAY
IS OPEN,
BREATHING IS ABSENT AND
MAINTAIN O2
SATS >95%
AEVALUATE
PULSE IS PRESENT:
PROVIDE POSITIVEPATIENT CONDITION
PRESSURE
VENTILATIONS
WITH OXYGEN.
MONITOR VITAL SIGNS
DELIVER
EACH
BREATH
OVER
SECOND
o HYPOPERFUSION (BP < 100ONE
SYSTOLIC)
WITH ENOUGH VOLUME TO CAUSE CHEST RISE
OBTAIN MEDICAL HISTORY
Oo PEDIATRIC
RATE: ONE BREATH EVERY 3-5
NAUSEA/VOMITING
o SECONDS
SURGERY
MAINTAIN
O2 SATS >95%
o TRAUMA
EVALUATE
REASSUREPATIENT
PATIENTCONDITION
OBTAIN
MEDICAL
GIVE NOTHING
BYHISTORY
MOUTH
oTRANSPORT
SEVERITYIN
OFPOSTIION
UNDERLYING
DISEASE?
OF COMFORT
o EVER SEEN PHYSICIAN OR HOSPITALIZED
FOR THIS?
o HAS THE PATIENT EVER BEEN INTUBATED?
o MEDICATION COMPLIANCE?
o DNR STATUS?
MONITOR VITAL SIGNS
REASSURE PATIENT
TRANSPORT
SECURE
AIRWAY.
REFER TO
ADVANCED AIRWAY
IV NS (RUN
TO MAINTAIN
PERFUSION)
PROCEDURES.
MONITOR ECG
IV
NS (BOLUS
AS MANAGEMENT
NEEDED TO MAINTAIN
PERFUSION)
CONSIDER
PAIN
PROTOCOL
MONITOR ECG
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
OBSTRUCTED
AIRWAY
VOMITING
KEY
BASIC EMT
ADVANCED EMT









ASSESS
AIRWAY
OPEN AND
MANAGE AIRWAY
MAINTAIN O2 SATS >95%
FOREIGN BODY OBSTRUCTION:
PATIENT CONDITION
oEVALUATE
IF PATIENT ABLE TO SPEAK / COUGH – ALLOW
MONITOR
SIGNS CLEARING AIRAWAY BY
PATIENTVITAL
TO ATTEMPT
o SELF
HYPOPERFUSION (BP < 100 SYSTOLIC)
OBTAIN MEDICAL HISTORY
oo IF
PATIENT UNABLE TO SPEAK / COUGH –
NAUSEA/VOMITING
ADULT– DELIVER ABDOMINAL THRUSTS.
o SURGERY
REPEAT UNTIL EFFECTIVE OR PATIENT IS
o TRAUMA
UNRESPONSIVE
REASSURE PATIENT
NOTHING
BY MOUTH BEGIN CPR. FINGER
oGIVE
IF PATIENT
UNRESPONSIVE
TRANSPORT
IN
COMFORT
SWEEP ONLY POSTIION
TO REMOVEOF
VISIBLE
FOREIGN
BODY.




TRANSPORT TO NEAREST APPROPRIATE HOSPITAL IF
UNABLE TO CLEAR AIRWAY IN 60 SECONDS
ATTEMPT
TO VISUALIZE
OBSTRUCTION
WITH
IF NAUSEA
AND VOMITING
PRESENT
LARYNGOSCOPE AND REMOVE WITH MAGILL
FORCEPS.
ADMINISTER ONDANSETRON (ZOFRAN) 4MG SLOW IV
IF
AIRWAY
CAN NOT BE CLEARED PERFORM
PUSH
OR IM
CRICOTHYROIDOTOMY
PARAMEDIC
MED CONTROL
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
OBSTRUCTED
AIRWAY
VOMITING
BASIC
KEY
BASIC EMT
ADVANCED EMT
PARAMEDIC
P
E
D
I
A
T
R
I
C
S










ASSESS AIRWAY
OPEN AND MANAGE AIRWAY
MAINTAIN O2 SATS >95%
FOREIGN BODY OBSTRUCTION:
PATIENT
CONDITION
oEVALUATE
IF PATIENT
ABLE TO
SPEAK / COUGH – ALLOW
MONITOR
VITAL
SIGNS
PATIENT TO ATTEMPT CLEARING AIRAWAY BY
o SELF
HYPOPERFUSION (BP < 100 SYSTOLIC)
OBTAIN MEDICAL HISTORY
oo IF
PATIENT UNABLE TO SPEAK / COUGH –
NAUSEA/VOMITING

CHILD > 1 YEAR OLD – DELIVER ABDOMINAL
o SURGERY
THRUSTS. REPEAT UNTILL EFFECTIVE OR
o TRAUMA
PATIENT IS UNRESPONSIVE
REASSURE
PATIENT

INFANT
< 1 YEAR OLD – DELIVER SERIES OF
GIVE NOTHING
BY MOUTH
FIVE BACKBLOWS
AND FIVE CHEST
TRANSPORT
IN POSTIION
OF COMFORT
THRUSTS.
REPAT UNTILL
EFFECTIVE OR
PATIENT IS UNRESPONSIVE
o
IF PATIENT UNRESPONSIVE BEGIN CPR. FINGER
SWEEP ONLY TO REMOVE VISIBLE FOREIGN
BODY.
o
IF AIRWAY OBSTRUCTION DUE TO MEDICAL
CAUSE- TREAT UNDERLYING CAUSE

CROUP – KEEP PATIENT UPRIGHT,
ADMINSTER HUMIDIFIED OXYGEN IF
AVAILABLE

EPIGLOTITIS – TRANSPORT UPRIGHT
IMMEDIATELY. DO NOT AGITATE THE CHILD.
DO NOT EXAM THE THROAT.
TRANSPORT TO NEAREST APPROPRIATE HOSPITAL
IF UNABLE TO CLEAR AIRWAY IN 60 SECONDS



ADMINISTER
EPINEPHRINE
1:1000 0.5 MG/KG (MAX 5
IV NS (RUN TO
MAINTAIN PERFUSION)
MG
OR
5
ML)
IN
NEBULIZER
/ AEROSAL FOR CROUP
MONITOR ECG
PATIENT.
CONSIDER PAIN MANAGEMENT PROTOCOL

ATTEMPT
TO VISUALIZE
OBSTRUCTION
WITH
IF NAUSEA
AND VOMITING
PRESENT
LARYNGOSCOPE AND REMOVE WITH MAGILL
FORCEPS.
ADMINISTER ONDANSETRON (ZOFRAN) 4MG SLOW IV
PUSH OR IM



IF
AIRWAY
CANPERFUSION)
NOT BE CLEARED
IVPEDIATRIC
NS (RUN TO
MAINTAIN
PERFORM
CRICOTHYROIDOTOMY
MONITOR ECG
MED CONTROL
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
WHEEZING
VOMITING
KEY
BASIC EMT
ADVANCED EMT
PARAMEDIC










ASSESS
AND
MANAGE
AIRWAY
OPEN AND
MANAGE
AIRWAY
MAINTAIN
O2
SATS
>95%
MAINTAIN O2 SATS >95%
EVALUATE
EVALUATE PATIENT
PATIENT CONDITION
CONDITION
OBTAIN
MEDICAL
HISTORY
MONITOR VITAL SIGNS
oo SEVERITY
OF UNDERLYING
HYPOPERFUSION
(BP < 100 DISEASE?
SYSTOLIC)
oOBTAIN
EVERMEDICAL
SEEN PHYSICIAN
HISTORY OR HOSPITALIZED
THIS?
o FOR
NAUSEA/VOMITING
oo HAS
THE
PATIENT EVER BEEN INTUBATED?
SURGERY
oo MEDICATION
COMPLIANCE?
TRAUMA
o DNR STATUS?
REASSURE PATIENT
MONITOR
VITALBY
SIGNS
GIVE NOTHING
MOUTH
REASSURE
PATIENT
TRANSPORT IN POSTIION OF COMFORT
IF LUNG SOUNDS REVEAL WHEEZES:
o CONSIDER CPAP FOR ADULT PATIENTS
o ASSIST PATIENT WITH PRESCRIBED
METERED-DOSE-INHALER IF AVAILABLE
o IF ALLERGIC REACTION / ANAPHYLAXIS
SUSPECTED – SEE ALLERGIC REACTION /
ANAPHYLAXIS PROTOCOL
TRANSPORT



FOR
ASTHMAPERFUSION)
/ BRONCHITIS:
IV NSSUSPECTED
(RUN TO MAINTAIN
ADMINISTER
IPATROPIUM BROMIDE (ATROVENT)
MONITOR ECG
0.5
MG AND PAIN
ALBUTEROL
SULFATE
(PROVENTIL)
CONSIDER
MANAGEMENT
PROTOCOL
3MG IN 3ML.
ADULT DOSE: 3ML BY NEBULIZER / AEROSAL
ABLUTEROL AEROSALS CAN BE ADMINSTERED
PRN IF FURTHER TREATMENT NEEDED.

CONSIDER
METHYLPREDNISOLONE
(SOLUIF NAUSEA
AND VOMITING PRESENT
MEDROL)
ADULT
DOSE: ONDANSETRON
125 MG SLOW IV(ZOFRAN)
PUSH
ADMINISTER
4MG SLOW
CONSIDER
IF
PATIENT
REMAINS
IN
DISTRESS:
IV PUSH OR IM
EPINEPHRINE 1:1000 0.3 MG IM (DO NOT
ADMINISTER IF PATIENT IS PREGNANT OR HAS
HISTORY OF HEART DISEASE)
INTUBATE AS INDICATED – SEE PROCEDURAL
SEDATION PROTOCOL.



MED CONTROL
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
WHEEZING
VOMITING
KEY
BASIC EMT
ADVANCED EMT
PARAMEDIC
P
E
D
I
A
T
R
I
C
S
MED CONTROL


















ASSESS
AND
MANAGE
AIRWAY
OPEN AND
MANAGE
AIRWAY
MAINTAIN
O2
SATS
>95%
MAINTAIN O2 SATS >95%
EVALUATE
EVALUATE PATIENT
PATIENT CONDITION
CONDITION
OBTAIN
MEDICAL
HISTORY
MONITOR VITAL SIGNS
oo SEVERITY
OF UNDERLYING
HYPOPERFUSION
(BP < 100 DISEASE?
SYSTOLIC)
oOBTAIN
EVERMEDICAL
SEEN PHYSICIAN
HISTORY OR HOSPITALIZED
THIS?
o FOR
NAUSEA/VOMITING
oo HAS
THE
PATIENT EVER BEEN INTUBATED?
SURGERY
oo MEDICATION
COMPLIANCE?
TRAUMA
o DNR STATUS?
REASSURE PATIENT
MONITOR
VITALBY
SIGNS
GIVE NOTHING
MOUTH
REASSURE
PATIENT
TRANSPORT IN POSTIION OF COMFORT
IF LUNG SOUNDS REVEAL WHEEZES:
o ASSIST PATIENT WITH PRESCRIBED
METERED-DOSE-INHALER IF AVAILABLE
o IF ALLERGIC REACTION / ANAPHYLAXIS
SUSPECTED – SEE ALLERGIC REACTION /
ANAPHYLAXIS PROTOCOL
TRANSPORT
FOR
ASTHMAPERFUSION)
/ BRONCHITIS:
IV NSSUSPECTED
(RUN TO MAINTAIN
ADMINISTER
IPATROPIUM
BROMIDE
(ATROVENT)
MONITOR ECG
0.5 MG AND ALBUTEROL SULFATE (PROVENTIL)
CONSIDER PAIN MANAGEMENT PROTOCOL
3MG IN 3ML.
PEDIATRICS DOSE: 1.5 ML BY NEBULIZER /
AEROSAL
ABLUTEROL AEROSALS CAN BE ADMINSTERED
PRN IF FURTHER TREATMENT NEEDED.
FOR SUSPECTED BRONCHIOLITIS (CHILDREN < 2
YEARS OLD): ADMINISTER EPINEPHRINE 1:1000 0.5
MG/KG (MAX 5 MG OR 5 ML) IN NEBULIZER /
AEROSAL FOR CROUP PATIENT.
CONSIDER
METHYLPREDNISOLONE
(SOLU-MEDROL)
IF NAUSEA
AND VOMITING PRESENT
PEDIATRIC DOSE: 2 MG/KG SLOW IV PUSH
IF
PATIENT REMAINS
IN RESPIRATORY
ADMINISTER
ONDANSETRON
(ZOFRAN)DISTRESS
4MG SLOW
CONSIDER
1:1000
IV PUSH OREPINEPHRINE
IM
PEDIATRIC DOSE: 0.01 MG/KG IM
INTUBATE AS INDICATED – SEE PROCEDURAL
SEDATION PROTOCOL.
RESPIRATORY
EMERGENCIES
ABDOMINAL PAIN
/ NAUSEA
PULMONARY
EDEMA
VOMITING
KEY
BASIC EMT
ADVANCED EMT
















ASSESS
AND
MANAGE
AIRWAY
OPEN AND
MANAGE
AIRWAY
MAINTAIN
O2
SATS
>95%
MAINTAIN O2 SATS >95%
EVALUATE
EVALUATE PATIENT
PATIENT CONDITION
CONDITION
OBTAIN
MEDICAL
HISTORY
MONITOR VITAL SIGNS
oo SEVERITY
OF UNDERLYING
HYPOPERFUSION
(BP < 100 DISEASE?
SYSTOLIC)
oOBTAIN
EVERMEDICAL
SEEN PHYSICIAN
HISTORY OR HOSPITALIZED
THIS?
o FOR
NAUSEA/VOMITING
oo HAS
THE
PATIENT EVER BEEN INTUBATED?
SURGERY
oo MEDICATION
COMPLIANCE?
TRAUMA
oREASSURE
DNR STATUS?
PATIENT
MONITOR
VITALBY
SIGNS
GIVE NOTHING
MOUTH
REASSURE
PATIENT
TRANSPORT IN POSTIION OF COMFORT
CONSIDER CPAP FOR ADULT PATIENTS
TRANSPORT
IV
IV NS
NS (RUN
(RUN TO
TO MAINTAIN
MAINTAIN PERFUSION)
PERFUSION)
MONITOR
ECG
MONITOR ECG
ADMINISTER
NITROGLYCERIN
SL–
ONE TABLET OR
CONSIDER PAIN
MANAGEMENT
PROTOCOL
SPRAY IF BP ABOVE 100 MMHG. MAY REPEAT
TWICE IF BP REMAINS GREATER THAN 100 MMHG
IF PATIENT
REMAINS
INVOMITING
DISTRESSPRESENT
AND SPB > 100
IF NAUSEA
AND
MMHG, ADMINISTER MORPHINE OR FENTANYL
(SUBLIMAZE)
ADMINISTER ONDANSETRON (ZOFRAN) 4MG SLOW
INTUBATE
ASIM
INDICATED – SEE PROCEDURAL
IV PUSH OR
SEDATION PROTOCOL.
PARAMEDIC
MED CONTROL