Respiratory Emergencies
Jessica Owen, CCRN
Anatomy
Anatomy
Physiology
Inspiration
Active process
Chest cavity expands
Intrathoracic pressure falls
Air flows in until pressure equalizes
Expiration
Passive process
Chest cavity size decreases
Intrathoracic pressure rises
Air flows out until pressure equalizes
Physiology
Developmental Variances of a
Child’s Respiratory System
Developmental Variances of a
Child’s Respiratory System
Adequate Breathing
• Normal rate and depth
• Regular breathing
pattern.
• Normal breath sounds
on both sides of lungs.
• Equal chest rise and
fall.
• Pink, warm, dry skin.
Inadequate Breathing
Breathing rate < 12 or > 20
Shallow or irregular respirations
Unequal chest expansion
Decreased or absent lung sounds
Accessory muscle usage
Pale or cyanotic skin color
Cool, clammy skin appearance
Pediatric Note
Normal Respiratory Rates by Age
Age
Breaths/min
Infant (< 1 year)
30 to 60
Toddler (1 to 3 years)
24 to 40
Preschooler (4 to 5 years)
22 to 34
School Age (6 to 12 years)
18 to 30
Adolescent (13 to 18 years)
12 to 16
Obstructive Pathophysiology
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Tongue
Foreign body obstruction
Anaphylaxis & Angioedema
Facial trauma and inhalation injuries (burns)
Epiglottitis and Croup
Aspiration
Restrictive Pathophysiology
• Asthma
• COPD
Diffusion Pathophysiology
• Pulmonary Edema: left-sided heart
failure, toxic inhalations, near drowning
• Pneumonia
• Pulmonary Embolism: blood clots,
amniotic fluid, fat embolism
Ventilation Pathophysiology
• Trauma: rib fractures, flail chest,
spinal cord injuries
• Pneumothorax & Hemothorax
• Diaphragmatic hernia
• Pleural effusion
• Morbid obesity
• Neurological/muscular diseases:
polio, MD, myasthenia gravis
Control System Pathophysiology
• Head trauma
• CVA
• Depressant drug toxicity: narcotics,
sedative-hypnotics, ethyl alcohol
Acute Respiratory Failure
OLD
SCHOOL
NEW
SCHOOL
Acute Respiratory Failure
Old School
Type I
Hypocapnic Failure
Decreased oxygen level with a normal or low CO₂
Ventilation – Perfusion Imbalance
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Pulmonary Edema
Pulmonary Embolism
Aspiration Pneumonia
Asthma
ARDS
Type II
Hypercapnic Failure
Decreased oxygen level with a high CO₂ level
Respiratory Mechanical Performance
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Drug Overdose
COPD
CVA
Spinal Cord Injury
MS: ALS, GB, MG
Pneumothorax
Hypophosphatemia
Acute Respiratory Failure
New School
V/Q Mismatch
Ventilation – Perfusion Imbalance
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COPD
Asthma
Atelectasis
Pulmonary Edema
Pulmonary Embolism
Aspiration Pneumonia
Shunt
No Contact Between Blood and Alveoli
• ARDS
Initial Assessment
Initial Impression:
• Mental status
• Respiratory rate and effort
 If not responsive and not breathing or no normal
breathing GET HELP!
 With infants & children, if arrest is unwitnessed
perform 2 minutes of CPR before leaving.
• Pulse (rate & character)
 If no pulse start compressions and breaths (30:2)
with 2 rescuers children & infant (15:2)
 If pulse but not breathing adequately, open the
airway a perform rescue breathing.
Rescue Breathing
Rescue Breathing for Adults
Rescue Breathing for Infants and
Children
• Give 1 breath every 5 to 6 seconds
(about 10 to 12 breaths per minute).
• Give 1 breath every 3 to 5 seconds
(about 12 to 20 breaths per minute).
• Give each breath in 1 second.
• Each breath should result in visible chest rise.
• Check pulse about every 2 minutes.
Focused Assessment
Signs and symptoms
Allergies
Medications
Pertinent past medical history
Last meal or intake
Events leading to symptoms
Focused Assessment
Crackles (Rales)
• CHF
• Pneumonia
Wheezing or Rhonchi
• Pneumonia
• Aspiration
• COPD
• Asthma
Stridor
• FBAO
• Croup
• Anaphylaxis
• Epiglottitis
• Airway burn
Watch for critical signs: JVD, tracheal deviation, paradoxical chest movement.
Plan
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Help (?) – Rapid Response vs. Code Blue
Put patient in position of comfort.
Oxygen.
Assist with medications.
Calm and reassure.
Minimize patient movement.
Higher level of care.
Golden Rules
• If you are thinking about giving O2, then give it!
• If you can’t tell whether a patient is breathing
adequately, then they aren’t!
• If you’re thinking about assisting a patient’s
breathing, you probably should be!
• When a patient quits fighting it does not mean
that they are getting better!
Case Study
A 93 year old woman with dementia became
cyanotic and apneic during Thanksgiving
dinner at her family residence. The Heimlich
maneuver was performed by family and the
aspirated material was retrieved, which was
recognized as two pieces of turkey. The
patient had continued respiratory distress and
was immediately brought to the emergency
department, where her oxygen saturation was
93% on 10 liters/minute of oxygen via nasal
cannula. A chest radiograph showed a
collapsed left lower lobe, and emergency
bronchoscopy removed two pieces of “food
stuff” from the left main stem bronchus. She
promptly recovered and was discharged two
days later, with a swallowing study
recommended as an outpatient.
Foreign Body Airway Obstruction
• Obstruction may result from head position,
tongue, aspiration, or foreign body.
• Be prepared to treat quickly and
aggressively.
• If you suspect a complete obstruction for a
conscious victim, use manual technique
appropriate for age.
• < 1 year: Give 5 back slaps followed by 5
chest thrusts
• >1 year: Give abdominal thrusts
• If victim becomes unresponsive, start CPR,
beginning with chest compressions (even if
pulse is palpable. Before you deliver
breaths, look into the mouth. If foreign body
is visible and easily removable, remove it.
• Do not perform a blind finger sweep!
Case Study
A 6-year-old male presents conscious, alert
and oriented, sitting up in bed in a “sniffing”
position and complaining of a sore throat. He
has a strong and rapid radial pulse, and his
respiratory rate is normal, but you note
inspiratory stridor with each breath. His skin
is warm and dry. His mother says he went to
bed last night without any complaint but woke
up this morning with a sore throat and fever.
Since he awoke 5 hours ago, the patient’s
fever has risen to 102.3ºF (39.0ºC), and the
stridor developed. The mother reports the
patient has no significant medical history and
takes no medications. He has not received all
of his vaccinations to date, as the parents are
concerned about vaccine side-effects. She is
not aware of any recent trauma or potential
for foreign body ingestion.
Airway Infections
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Epiglottitis
Croup
Ludwig’s angina
Bronchiolitis
Influenza
Pneumonia
Case Study
A 38-year-old woman presented to the ED after visiting a relative in the hospital.
She gave a 5-year history of recurrent conjunctival edema and rhinitis when
blowing up balloons for her children's birthday parties. In the year prior to visit,
three successive visits to her dentist triggered marked angioedema of her face
on the side opposite to that requiring dental treatment. The swellings took 48
hours to subside.
On the day of ED visit, she visited a critically ill relative in hospital. The patient
was on reverse barrier precautions and visitors were required to wear gown
and gloves. About 20 min after putting on the gloves her face and eyes became
swollen, she felt wheezy and developed a pounding heart beat and lightheadedness. Her tongue started to swell.
In the Emergency Department where she was given intramuscular epinephrine
(adrenaline) and intravenous hydrocortisone. She recovered rapidly but was
kept under observation overnight.
Anaphylaxis
• Characterized by respiratory distress (SOB, wheezes &/or
stridor, hoarseness, pain with swallowing, cough);
tachycardia or bradycardia; hives; swelling of tongue, lips,
&/or mouth; and hypotension.
• Usually results from body response to allergen (medications
or additive, contact with natural rubber latex, contact with a
solution, environmental, stings or bites).
• Airway obstruction due to angiodema is major concern!
• Follow Allergic reaction protocol.
Case Study
A 15 year old known asthmatic was admitted to the Emergency room after a week
of progressive difficulty breathing. Her mother states that she had been sick with
and upper respiratory infection and had been using her albuterol inhaler almost
hourly until she ran out the day prior. On arrival she is alert, speaking in clipped
sentences; sitting upright and appears very anxious. BP 150/90, HR 122, RR 32,
O2 saturation 90% on room air.
Over the course of her treatment in the ER she developed progressive hypoxia
that was refractory to standard treatment requiring intubation. She was then
transferred to the ICU and placed on continuous bronchodilator therapy through
the ventilator. After two hours of continuous bronchodilator therapy there was
dramatic improvement in her breath sounds. She continued to improve over the
next 24 hours, and was extubated the next day.
Status Asthmaticus
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Severe asthma attack
that doesn't respond to
usual use of inhaled
bronchodilators and is
associated with
symptoms of potential
respiratory failure.
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• Signs & symptoms:
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Persistent SOB
The inability to speak
in full sentences
Breathlessness at
rest
Chest tightness
Cyanosis
Agitation, confusion,
or an inability to
concentrate
Hunched shoulders
and accessory
muscle use
Tripod positioning
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Beta-agonists and
corticosteroids are
mainstays in the treatment
of status asthmaticus.
Oxygen therapy is essential,
with hypoxia being the
leading cause of death in
children with asthma.
Indications for intubation &
mechanical ventilation:
• Apnea or respiratory
arrest
• Diminishing LOC
• Impending respiratory
failure marked by
significantly rising PCO2
with fatigue & decreased
air movement
• Significant hypoxemia
that is unresponsive to
supplemental oxygen
Case Study
A 64-year-old female status post aortic valve replacement for severe aortic
stenosis late on POD 2 suddenly experienced severe shortness of breath and
began to cough up frothy pink sputum. The patient remained alert but became
mildly confused, on auscultation exhibited end-inspiratory crackles throughout her
lung bases, a pulse of 123 beats/min, a blood pressure of 121/73 mm Hg, and a
respiratory rate of 28-32.
Within 25 minutes of symptoms, she was intubated for ventilation, vigorous
diuresis occurred and the patient's initially normal blood pressure plummeted to
<70 mm Hg, systolic. At that point, the ECG also showed that the patient had
developed atrial fibrillation (AF) with a rapid ventricular rate of 124 beats/min. The
patient then received 150 mg IV Amiodarone over 10 minutes and was cardioverted
at 120 J via a biphasic defibrillator into a NSR.
Acute Pulmonary Edema
• Signs & symptoms:
• Paroxysmal nocturnal dyspnea
• Frothy, pink sputum
• Tachypnea
• Tachycardia
• JVD
• Diaphoretic
• Presence of a gallop
• Crackles
Case Study
A 21-year-old female presented to the emergency department of a local hospital
with a 6-week history of increasing muscle fatigue, dizziness and exhaustion. Prior
to her arrival at the ER, her breathing became significantly more difficult, with the
development of sharp chest pain. She denied cough, hemoptysis, wheeze,
palpitations, or upper arm or lower leg pain or swelling.
Just prior to the development of her initial symptoms she had taken a 3-hour flight
home from a vacation. She was recently started on oral contraception, but denies
smoking and is unsure about her families history of clotting disorders. A CT of her
chest showed multiple pulmonary embolisms. She was started on SQ Lovenox and
discharged home a few days later.
Pulmonary Embolism
• A blockage of the main artery of
the lung or one of its branches by a
substance that has travelled from
elsewhere in the body through the
bloodstream (embolism).
• Signs & symptoms:
• Dyspnea/tachypnea
• Cyanosis
• Acute pleuritic pain on
inspiration
• Hemoptysis
• Hypoxia
Case Study
A 57-year-old male was admitted to the ICU after suffering a sudden cardiac arrest
at home. His son provided 18 minutes of chest compression prior to EMS arriving
and defibrillating the victim into a perfusing rhythm. The victim remained
unresponsive, was intubated and cooling measures were instituted in the field.
On arrival to the ICU he was tachycardic with frequent PVCs. An ABG revealed a
PO2 of 60 and a CO2 of 56. Breath sounds were slightly decreased on the right side
and peak inspiratory pressures on the ventilator were elevated.
A stat portable chest X-ray revealed a tension pneumothorax on the right side. A
chest tube was inserted on the right side with re-expansion of the lung and
resolution of his symptoms.
Tension Pneumothorax
• Spontaneous or trauma induced
• Accumulation of air in the pleural space
• Signs & symptoms:
• Dyspnea
• One-sided chest pain
• Absent or decreased breath sounds
• Tachycardia
• Tachypnea
• Tracheal deviation away form
affected side
• Hyperresonant percussion note of
the affected side
• Reduced expansion and decreased
movement of the affected side
• Displacement of the apex beat
• Resonant sound when tapping the
sternum.
Case Study
A 20 year old male, brought to ER by ambulance crew with altered level of
consciousness and respiratory depression. EMS states that the patient was found in
a collapsed state by friend. The friend was unable to rouse patient and called 911.
EMS inserted an OPA and started O2 @15 liters via BVM, in addition to administering
Naloxone IM.
On arrival to ER patient somnolent, ST at rate 120, BP 95/40, RR 8, O2 saturation
99%. Endotracheal intubated and fluid resuscitation commenced. Transferred to the
ICU on mechanical ventilation and a Narcan drip. Less than 24 hours later patient
was extubated and admitted to smoking heroin.
Depressant Drug Toxicity
Narcan is used to reverse opioid ingestion and serious opioid induce side effects.
• Signs of opioid overdose:
• Somnolent
• Respiratory compromise (RR < 7, non-patent airway,
low O2 saturation)
• Pin point pupils
Dilute 0.4mg Naloxone (1ml ampule) with 9ml NS in
10ml syringe (0.04 mg Narcan/ 1 ml)
• Generally 0.04 mg administered IV over 30 seconds
every 2-3 minutes until a change in alertness &/or
respiratory depression is observed.
Flumazenil is a benzodiazepine receptor antagonist.
Treatment of overdose:
• Initial dose: 0.2mg (2ml) given over 30 seconds,
followed by 0.3mg (3ml) after 30 seconds.
• Additional dose: 0.5mg (5ml) given over 30 seconds,
every 1 minute to a maximum dose of 3mg total