Respiratory Emergencies

The respiratory system is necessary to breathe. Breathing, or respiration, is the process of drawing into the body oxygen and expelling carbon dioxide from the body. Carbon dioxide provides the trigger in the brain to breathe. The organs and tissues involved in breathing include the nose, mouth, oropharynx, nasopharynx, epiglottis, trachea, cricoid cartilage, larynx, bronchi, lungs, alveoli, and diaphragm.

The respiratory cycle consists of inspiration, or inhalation, and expiration, or exhalation. Inspiration is an active process involving the contraction of several muscles to increase the size of the chest cavity. Expiration is a passive process which involves the relaxation of the rib muscles and the diaphragm. 

Normal breathing is evaluated by observing rate, rhythm, and quality as indicated in the following table.

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Inadequate breathing is breathing that is insufficient to support life or normal, healthy function of the body. 

Respiratory conditions are the leading cause of death in infants and children. The structure of the respiratory system in infants and children are different from adults primarily as follows:

  • Airway: Infant and children airways are smaller than adults and more easily obstructed.
  • Tongue: Infant's and children's tongues are proportionately larger and take up a greater percent of the space in the mouth than adults.
  • Trachea: The trachea is smaller, softer, and more flexible in infants and children than in adults. The cricoid cartilage is less developed and less rigid also.
  • Diaphragm: Since the chest wall is softer in infants and children than in adults, they depend more heavily on the diaphragm to breathe. This is the reason that they exhibit more "seesaw" breathing.

Artificial Ventilation

 The adequate rate for artificial ventilation in adults is 12 breaths/minute and 20 breaths/minute for infants and children. 

When adults experience a decrease in oxygen in the bloodstream (hypoxia), their pulse increases. With infants and children, they may initially experience a slight increase in pulse but, the pulse will usually drop significantly. Bradycardia, or slow pulse, in infants and children usually means a respiratory emergency! Adequate airway management is the most important aspect of patient care in infants and children. 

Whenever the chest does not rise and fall with each artificial ventilation, the force of ventilation must be increased. If this still does not produce chest movement, head-tilt/chin-lift or jaw thrust must be checked andperformed. If necessary, use an oropharyngeal or nasopharyngeal airway as needed to prevent the tongue from obstructing the airway. 

Do not put anything in the mouth and transport as quickly as possible if any of the following signs of lower respiratory problems are noted:

  • wheezing
  • increased breathing effort on exhalation
  • rapid breathing without stridor ( a harsh, high-pitched sound)

   Signs of difficulty breathing include:

  • increased pulse rate
  • decreased pulse rate
  • pale, cyanotic, or flushed skin
  • noisy breathing (wheezing, gurgling, snoring, crowing, stridor)
  • inability to speak full sentences due to breathing difficulty
  • use of accessory muscles to breathe
  • retractions
  • altered mental status
  • coughing
  • flared nostrils, pursed lips
  • patient positioning (tripod- patient leans forward with hand on knee or other object; sits with feet dangling and leans forward)
  • unusual anatomy (barrel chest)

The focused history and physical exam includes appropriate interview and examination of the chest and respiratory structures. The EMT should use OPQRST to guide the questions. 

Patient Care

   When a patient is suffering from breathing difficulty, the following care should be provided:

  • assessment of airway and assist respiration with artificial ventilation.
  • oxygen is the main treatment for respiratory difficulty. Use a nonrebreather mask at 12-15 liters per minute if patient is breathing adequately. Supplemental oxygen should be provided along with artificial ventilations if the patient has inadequate breathing. Use a nasal cannula only if the patient cannot tolerate the mask.
  • position the patient in the most comfortable position which is usually sitting up. With inadequate breathing, the patient must be supine to receive artificial ventilations.
  • prescribed inhalers may be used if the patient has one with them. The patient may be assisted in using this after consultation with medical direction.

Respiratory Diseases

   Chronic obstructive pulmonary disease (COPD) include diseases such as emphysema, bronchitis, and black lung disease. They are usually caused by cigarette smoking but, may be caused by chemical pollutants, air pollution, chemicals, or frequent infections. A common feature is the breakdown of the alveoli which greatly reduces the surface area for respiratory exchange.

   Sometimes, COPD patients develop a hypoxic drive to trigger respirations. Some COPD patients develop a tolerance to increased levels of carbon dioxide which causes the brain to rely on oxygen levels as the trigger to breathe instead. The higher levels of oxygen administration, in rare cases, may lead to a decrease in respiratory effort or even respiratory arrest. 

   Asthma is an episodic disease and is not classified as a COPD. It is not continual as is emphysema or bronchitis and does not produce a hypoxic drive. Asthma attacks may be triggered by allergic reactions to something injected, inhaled, or swallowed by the patient. Attacks may be precipitated by insect stings, air pollutants, infection, strenuous exercise, or emotional stress. 

   Prescribed inhalers are often prescribed for patients with respiratory problems that lead to bronchoconstriction. The medicine in these inhalers are called bronchodilators which dilate the bronchi and air passageways to make breathing easier.



 EMT Challenge: Can you diagnose this patient from the x-ray?

Review Questions:

1. List the normal rates of breathing for infants, children and adults.

2. List the signs of adequate breathing.

3. Explain the treatment you would give a patient with inadequate breathing.

4. List the signs and symptoms of breathing difficulty.

5. What treatments would you give to a patient with breathing difficulty when their breathing is adequate?

6.  Explain all the steps from start to finish when helping a patient use a prescribed inhaler.

7. What are the major differences between adult and infant/child respiratory systems?

8. What are the important special considerations in assessing and treating infants and children with respiratory problems?

9. List in proper order, the structures of the respiratory system.

10. Rapid respiratory rate, diminished breath sounds, unequal chest expansion, and tripod positioning are all signs of what?

11. What is the medication of choice in treating a patient with breathing difficulty?

12. All of the following are signs of adequate air exchange EXCEPT:

(a) unequal chest expansion

(b) regular rhythm

(c) rate between 12 and 20 breaths per minute

(d) equal, clear breath sounds

13. A conscious patient with adequate breathing complains of difficulty breathing. In what position should this patient be transported?

(a) lying down with legs elevate

(b) in a position that is comfortable to the patient

(c) sitting forward with knees flexed

(d) sideways, to facilitate airway management

14.You are treating a pediatric patient who is in need of oxygen; however, the child is fighting the mask on her face. You should:

(a) immobilize the patient and continue administration of oxygen     

(b) deliver oxygen by holding the mask in front of the child's face

(c) discontinue oxygen administration

(d) have the parent hold the child's arms down to facilitate use of the mask

15. You respond to a 27-year-old patient who has a bluish coloration of the skin. Your assessment reveals an open airway and a respiratory rate of 6 breaths per minute. The proper device to deliver oxygen and ensure adequate breathing would be:

(a) nasal cannula at 4 liters of oxygen per minute

(b) non-rebreather mask at 8 liters of oxygen per minute

(c) bag-valve mask ventilator with oxygen reservoir and assisted ventilations

(d) metered dose inhaler followed by 100% oxygen via non-rebreather