Respiratory distress emergencies: patient management and stabilisation

By Cristiano Antonino On Jan 29, 2023

Respiratory distress (or shortness of breath) is the third most common emergency that EMS professionals respond to, accounting for more than 12% of all Emergency calls

Respiratory distress, also called acute respiratory distress syndrome (ARDS), is respiratory failure caused by rapid onset of widespread inflammation in the lungs

It can occur in patients who are critically ill or significantly injured.

Symptoms can include shortness of breath, rapid breathing, and bluish skin coloration.

Respiratory distress can be a serious, even fatal, condition.

Anyone who experiences these symptoms should seek emergency medical care immediately.

Diagnosing the cause of respiratory distress is not easy and requires clinical knowledge, a careful physical examination, and attention to detail.

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What is Respiratory Distress?

Respiratory distress, also called acute respiratory distress syndrome (ARDS), is respiratory failure caused by rapid onset of widespread inflammation in the lungs.

Patients with ARDS have severe shortness of breath and often are unable to breath without the support of a ventilator.

Symptoms can include shortness of breath (dyspnea), rapid breathing (tachypnea), and bluish skin coloration (cyanosis). Respiratory distress is a critical, often fatal condition, especially among the elderly and severely ill. If not properly treated, some extreme cases of respiratory distress can lead to a decreased quality of life.

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Respiratory distress can be primary or secondary:

Primary respiratory distress means the problem is in the lungs.
Secondary respiratory distress means the problem is somewhere else in the body and the lungs are compensating.

Possible primary respiratory distress problems include:

Anaphylaxis
Asthma
COPD
Pleural effusion
Pneumonia
Pneumothorax
Pulmonary edema

Possible secondary respiratory distress problems can include:

Diabetic ketoacidosis
Head trauma
Metabolic acidosis
Stroke
Sepsis
Toxicological overdose

Causes of Respiratory Distress and Treatment

Respiratory distress has a range of causes that can affect treatment, so EMTs must start by carefully considering the source of the condition.

For respiratory distress, the focus is usually on the lungs and auscultation (listening for sounds from the lungs, heart, and other organs).

An EMS provider’s assessment may include a physical exam, incident history, and vital signs before deciding the next step in treatment and transport of their patient.

The following are some of the most common types of respiratory distress and a brief overview of the appropriate treatment for each one.

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Airway Obstruction

There are many ways that a foreign object can lodge in an airway causing an obstruction.

For example, a stroke can damage swallowing reflexes, making the person more prone to choking.

Consumption of alcohol and some drugs can also suppress the gag reflex, which could also lead to choking.

Treatment: If the airway obstruction is mild and the patient is coughing forcefully, EMS providers may not interfere with the patient’s efforts to clear the obstruction.

If the patient has signs of severe airway obstruction, as indicated by a silent cough, cyanosis, or the inability to speak or breathe, you should intervene.

If in some cases a patient becomes unresponsive, you can perform a finger sweep to clear the airway obstruction, but only if you can see solid material blocking their airway.

Asthma

Asthma is a chronic, inflammatory disease of the airways.

Asthma attacks can be induced by many different causes including allergens, infections, exercise, and smoke.

Patients with asthma are very sensitive to things such as dust, pollen, drugs, air pollutants, and physical stimuli.

During an asthma attack, the muscles around the bronchioles tighten, the lining of the inside the bronchioles swells, and the inside of the bronchioles fills with thick mucus.

This severely restricts expiration of air from the lungs. Patients will often describe a history of asthma and have a prescription for a metered-dose inhaler.

Treatment. Basic Life Support treatment considerations include:

Calming the patient
Airway management
Oxygen therapy
Assisting with a prescribed inhaler

COPD

Chronic obstructive pulmonary disease (COPD) is a group of diseases that includes asthma, emphysema, and chronic bronchitis.

COPD causes a slow process of dilation and disruption of the airways and alveoli, and it includes several related irreversible conditions that limit the ability to exhale.

Symptoms of COPD include shortness of breath, fever, and increased sputum production.

The patient’s medical history can include conditions such as upper-respiratory infection, chronic bronchitis, emphysema, smoking, or working with hazardous substances such as chemicals, smoke, dust, or other substances.

Treatment. Common medications for COPD include:

Prednisone
Proventil
Ventolin
Atrovent
Azmacort

EMS treatment for a COPD patient with respiratory distress should include high flow oxygen.

Congestive Heart Failure

Congestive heart failure (CHF) results from too much fluid in the lungs, making it difficult to get air in.

This is in contrast to COPD patients, who typically experience difficulty getting the air out.

CHF occurs when the ventricles are weakened by a heart attack, underlying coronary artery disease, hypertension, or valve disease.

This impairs the heart’s ability to contract and empty during systole and blood backs up in the lungs and tissues of the body.

CHF is usually chronic with acute exacerbations.

During an acute episode, the patient will typically present sitting up, short of breath, diaphoretic, and pale, or cyanotic in color.

Breathing sounds can include rales or wheezes.

The medical history can include increased salt ingestion, respiratory infection, non-compliance with medications, angina, or symptoms of acute coronary syndrome.

Treatment. Common medications include:

ACE inhibitors
Furosemide (Lasix)
HCTZ (hydrochlorthiazide)
Beta-blockers
Angiotensin II receptor blockers
Digoxin (Lanoxin)

When treating patients who are suffering from congestive heart failure, seat the patient upright and administer high flow oxygen.

You may also consider positive pressure ventilation with a bag-valve-mask (BVM) if the patient is experiencing severe respiratory difficulty.

Inhalation Injuries

Inhalation injuries are caused by inhaling chemicals, smoke, or other substances.

Common symptoms include shortness of breath, coughing, hoarseness, chest pain due to bronchial irritation, and nausea.

Individuals with decreased respiratory reserve, including a history of COPD or CHF, are likely to experience an exacerbation of the disease.

Treatment: If a patient is in respiratory distress, treat immediately with high flow oxygen.

Assist breathing with a bag-valve-mask (BVM) if the respiratory effort is insufficient as indicated by a slow rate and poor air exchange.

Pneumonia

Symptoms of pneumonia include fever, chills, cough (often with yellowish sputum), shortness of breath, general discomfort, fatigue, loss of appetite and headache.

There can be chest pain associated with breathing (usually sharp and stabbing in nature) and worsened by coughing or deep inspirations.

Other signs that sometimes present are rales, clammy skin, upper abdominal pain, and blood-tinged sputum.

Treatment: Emergency care for pneumonia depends on the severity of the patient’s breathing difficulty but may include oxygen therapy.

Pneumothorax

A pneumothorax is the presence of air between the two layers of the pleura—which are the membranes lining the thorax and enveloping the lungs.

It is caused when an internal or external wound allows air to enter the space between these pleural tissues, which can cause the lungs to collapse.

A pneumothorax can occur spontaneously (e.g., a rupture caused by disease or localized weakness of the lung lining) or as a result of trauma (e.g., gunshot or stab wound).

People who have a prior history of pneumothorax or COPD may be more at higher risk of experience this medical condition.

In some rare instances, even forceful coughing can cause a pneumothorax.

A pneumothorax can cause sharp chest pain and shortness of breath.

The patient’s breathing will sound diminished and you may be able to feel air coming from under the patient’s skin.

Treatment: EMS treatment of a pneumothorax includes high-flow oxygen. Be judicious with your use of positive-pressure ventilation. It can turn a spontaneous pneumothorax into a life-threatening tension pneumothorax.

Tension Pneumothorax

A tension pneumothorax is a progressively worsening pneumothorax that begins to impinge on the function of the lungs and the circulatory system.

It is caused when a lung injury acts like a one-way valve that allows free air to move into the pleural space but prevents the free exit of that air.

Pressure builds inside the pleural space and compresses the lungs and other organs.

Early signs of a tension pneumothorax include:

Increased dyspnea
Cyanosis
Signs of shock
Distended neck veins
Shift in PMI (Point of maximum intensity, where the heart is the loudest through auscultation)
Tracheal displacement
Tracheal deviation

Treatment: If the patient is hypotensive or showing signs of hypoperfusion, then EMS providers should initiate temporizing treatment for tension pneumothorax.

Open chest wounds should have a sealable dressing placed over them with a one-way air valve to prevent air build up.

This one-way valve can be created by applying an occlusive dressing and taping on three sides.

The EMS provider should perform needle decompression on the chest wall to release encased air.

Pulmonary Embolism

A pulmonary embolism (PE) can occur when a particle (such as a blood clot, fat embolus, amniotic fluid embolus, or air bubble) gets loose in the blood stream and travels to the lungs.

If the particle lodges in a major branch of the pulmonary artery, this can interrupt blood circulation to the lungs.

If blood cannot reach the alveoli, then it cannot be oxygenated.

This condition can be caused by immobility of the lower extremities, prolonged bed rest, or recent surgery.

Signs of PE are a sudden onset of shortness of breath, rapid breathing, chest pain worsened by breathing, and coughing up blood.

Treatment: Pulmonary embolism is a life-threatening condition and should be treated with high flow oxygen and rapid transport. Move the patient gently to avoid dislodging additional emboli (particles).

When to Call Emergency Number for Respiratory Distress

Breathing is something most of us do instinctively, day and night. We don’t even think about it.

So, if you experience shortness of breath or difficulty breathing it can be quite alarming.

If you experience shortness of breath that interferes with your daily routine or body functions, you should call Emergency Number or have someone drive you to the nearest Emergency Room immediately.

You should call Emergency Number immediately if you experience shortness of breath together with any of the following symptoms:

Chest pain
Dizziness
Pain that spreads to your arms, neck, jaw or back
Sweating
Trouble breathing
How to Treat Respiratory Distress

If you experience shortness of breath, or shortness of breath together with any of the symptoms listed above, you need to call Emergency Number or get to an ER immediately.

Treatment of respiratory distress requires a doctor.

The first goal in treating respiratory distress will be to improve the oxygen levels in your blood.

Without sufficient oxygen, your organs can fail. Increasing your blood oxygen levels can be achieved through supplemental oxygen or a mechanical ventilator that pushes air into your lungs.

Careful management of any intravenous fluids will also be critical.

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People with respiratory distress are usually given medication to:

Prevent and treat infections
Relieve pain and discomfort
Prevent blood clots in the legs and lungs
Minimize gastric reflux
Sedate

USA: How Do EMTs & Paramedics Treat Respiratory Distress

For all clinical emergencies, the first step is rapid and systematic assessment of the patient.

For this assessment, in the USA most EMS providers will use the ABCDE approach.

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is applicable in all clinical emergencies for immediate assessment and treatment.

It can be used in the street with or without any equipment.

It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for respiratory distress can be found on page 163 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO).

These guidelines are maintained by NASEMSO to facilitate the creation of state and local EMS system clinical guidelines, protocols, and operating procedures.

These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

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