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Respiratory Distress / Failure

Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-04-03

Overview

Respiratory distress is an increased work of breathing with the patient still compensating. Respiratory failure is the inability to maintain adequate gas exchange — ventilation (CO2 removal) or oxygenation (O2 delivery) is failing. Respiratory arrest is absent breathing requiring immediate BVM ventilation.

The EMT-B must rapidly distinguish the degree of respiratory compromise, initiate appropriate oxygen delivery, and determine when BVM ventilation is needed. Causes include obstructive lung disease (asthma, COPD), CHF/pulmonary edema, pneumonia, pneumothorax, upper airway obstruction, anaphylaxis, and neuromuscular failure.

Key Points

  • Assess for inadequate breathing — rate, depth, effort, quality of air exchange, SpO2
  • Respiratory distress signs: increased RR, use of accessory muscles, nasal flaring, retractions, tripod positioning, pursed-lip breathing, grunting, abnormal color
  • Silent chest is ominous — no wheeze in severe asthma/anaphylaxis means no air movement
  • "See-saw" (paradoxical) breathing in children indicates impending respiratory failure
  • Intervention ladder: positioning → supplemental O2 → BVM ventilation → advanced airway
  • BVM ventilation is indicated when breathing is absent or inadequate (rate too slow, too shallow, or both)
  • COPD patients and the "hypoxic drive" myth: O2 should NOT be withheld from a hypoxic COPD patient — the risk of hypoxia vastly outweighs the rare risk of respiratory depression from O2

Assessment Relevance

History (history-taking): - SAMPLE: Known respiratory conditions (asthma, COPD, CHF)? Current medications (bronchodilators, diuretics, steroids)? Last exacerbation? Triggers? Allergies? - OPQRST: Onset (sudden vs. gradual), provoked by (exertion, allergen, cold air), quality of breathing (wheeze vs. stridor vs. crackles), radiation (chest pain?), severity (scale 1-10), time course

Physical exam (secondary-assessment): - Respiratory rate and depth: tachypnea or bradypnea; shallow or deep - Work of breathing: accessory muscles, retractions (intercostal, supraclavicular, sternal), nasal flaring, tripod positioning - Breath sounds: wheeze (lower airway), stridor (upper airway), crackles/rales (fluid), diminished or absent - SpO2: <94% = supplemental O2; <90% = significant hypoxia - Skin: cyanosis (late, ominous), pallor, diaphoresis - Mental status: agitation, then decreasing LOC = worsening hypoxia/hypercarbia - Chest rise and symmetry

Procedures

Respiratory distress (compensating): 1. Position of comfort — sitting upright (tripod if needed) optimizes breathing mechanics 2. Supplemental oxygen to maintain SpO2 ≥94% — see oxygen-administration 3. If bronchospasm (asthma/COPD): patient-prescribed inhaler per protocol; ALS for albuterol nebulization 4. Transport with continuous monitoring; request ALS intercept if deteriorating

Respiratory failure / arrest (decompensated): 1. Immediate BVM ventilation — see bvm-ventilation 2. OPA or NPA airway adjunct — see bvm-ventilation 3. High-flow O2 (15 LPM) to BVM reservoir 4. Rate: 10–12 per minute adults (1 breath every 5–6 seconds) 5. Visible chest rise — not excessive volumes 6. Request ALS immediately for advanced airway

Causes to consider and direct assessment: - Asthma/COPD: wheeze, known history, prior hospitalizations - Pulmonary edema/CHF: crackles, JVD, peripheral edema, orthopnea - Anaphylaxis: see anaphylaxis — stridor + urticaria + exposure history - Pneumothorax: unilateral absent breath sounds, tracheal deviation (tension), trauma history - FBAO: see obstructed-airway — sudden onset, no fever, eating or playing (pediatric)

NM Protocol Notes

From NM EMS Treatment Guidelines (2022):

EMT-B/FR scope (General Respiratory Guidelines): - If respirations inadequate or absent, establish airway by: - Positioning maneuvers as indicated - CPAP (First Responder and above for severe respiratory distress/impending failure) - BVM ventilation with supplemental O2 for respiratory failure or arrest - OPA and/or NPA adjuncts to optimize BVM effectiveness - Suction as needed (oropharynx, nasopharynx) - Pulse oximetry and ETCO2 recommended

Asthma/COPD (EMT-B scope): - Supplemental oxygen: escalate NC → simple face mask → NRB as needed to maintain normal oxygenation - Suction if excessive secretions - If moderate to severe distress: - ALBUTEROL 5.0 mg nebulized (adult) OR LEVALBUTEROL 0.63–1.25 mg diluted in 3 cc isotonic, over 5–15 minutes — some patients may need continuous nebulizer during entire transport - Pediatric: ALBUTEROL 1.25–2.5 mg or LEVALBUTEROL 0.31–0.63 mg - Note: ALBUTEROL can be delivered via BVM for patients unable to provide effective respiratory exchange - IPRATROPIUM (Basic, Intermediate, Paramedic only) 250–500 mcg in conjunction with albuterol; not recommended for pediatric patients - Do not delay transport waiting for medication to take effect - If no improvement and refractory to other treatments: EPINEPHRINE 1:1,000 0.3 mg IM (adult) or 0.01 mg/kg IM (pediatric) — same device as for anaphylaxis - CPAP for severe respiratory distress (non-invasive positive pressure ventilation) - BVM should be utilized in children with respiratory failure

Croup (EMT-B/ALS): - Do NOT agitate the patient — this can precipitate complete airway obstruction - Supplemental oxygen escalating as needed; humidified O2 preferred - DEXAMETHASONE: Pediatric 0.6 mg/kg PO/IV/IO/IM (max 10 mg) — ALS scope - Nebulized EPINEPHRINE 1:1,000 5 mL (ALS scope) — for stridor at rest

Epiglottitis: - Do NOT put anything in the mouth — may cause complete obstruction - Allow patient to maintain position of comfort - Rapid transport to nearest facility; ALS intercept - Do NOT attempt to intubate adults if adequate air exchange

Pulmonary edema: - O2 to maintain SpO2 >94% - CPAP (EMT-B) - Nitroglycerin 0.4 mg SL every 5 min if severe distress and SBP >100, HR >60 (per protocol/medical direction) - Do NOT overhydrate — run IV at KVO

NREMT Relevance

High-frequency NREMT topic: - Respiratory distress vs. respiratory failure distinction - BVM rate: 10–12/min adults (1 breath every 5–6 seconds); 12–20/min pediatric - Visible chest rise (not excessive ventilation) - O2 delivery devices: NC (1–6 LPM mild distress) vs. NRB (10–15 LPM moderate/severe) - Wheeze = lower airway; stridor = upper airway - Silent chest in asthma = no air movement = most severe; do NOT be reassured by absent wheeze - COPD: do not withhold O2 from a hypoxic COPD patient - Croup: seal-bark cough, inspiratory stridor, age 6 months–3 years typically - Epiglottitis: high fever, drooling, tripod, do NOT examine throat

Sources

  • raw/protocols/nm-sop-guidelines-treatment-2022.pdf — General Respiratory Guidelines (p. 47–48); Asthma/COPD (p. 49–50); Croup (p. 51–52); Epiglottitis (p. 53); Pulmonary Edema (p. 55)