2.3 Respiratory Emergencies
Key Takeaways
- Respiratory distress is increased work of breathing with adequate gas exchange; respiratory failure is the failure of that gas exchange, marked by altered mental status, cyanosis, and inadequate or agonal breathing requiring assisted ventilation.
- Asthma and chronic obstructive pulmonary disease (COPD) cause expiratory wheezing from lower-airway constriction; nebulized albuterol is the AEMT-scope bronchodilator for these reversible airflow problems.
- Acute pulmonary edema from heart failure produces crackles, frothy or pink sputum, and severe distress; AEMT care centers on high-flow oxygen, positioning, and CPAP rather than albuterol.
- Anaphylaxis with airway compromise (stridor, swelling, hypotension) is treated with intramuscular epinephrine plus high-flow oxygen and airway support, and is a true time-critical emergency.
- Pediatric airways are smaller, the tongue is proportionally larger, and the narrowest point is the cricoid cartilage, so children desaturate faster and grunting, retractions, and nasal flaring are early failure signs.
Distress vs. Failure: The Core Distinction
The AEMT exam repeatedly tests whether a candidate can tell respiratory distress from respiratory failure, because the difference changes the intervention.
| Feature | Respiratory Distress | Respiratory Failure |
|---|---|---|
| Gas exchange | Still adequate | Inadequate / failing |
| Mental status | Anxious, alert | Altered, drowsy, unresponsive |
| Breathing effort | Increased work, fast | Slowing, shallow, irregular, or agonal |
| Skin | Normal to pale | Cyanotic, mottled |
| Intervention | Oxygen, position, medication (e.g., albuterol), possibly CPAP | Positive-pressure ventilation with a BVM |
A tiring patient who becomes quiet and sleepy is a red flag — silence is not improvement; it is often impending failure.
General Assessment
- Position — patients in distress instinctively assume the tripod position; do not force them to lie flat.
- Speech — count how many words the patient can say between breaths; one-to-two-word sentences signal severe distress.
- Lung sounds — wheezing (lower-airway constriction), crackles/rales (fluid), stridor (upper-airway obstruction/swelling), or absent/diminished sounds.
- Accessory muscle use, retractions, and tripoding indicate significant effort.
Asthma and COPD
Both produce expiratory wheezing from narrowed lower airways.
- Asthma — reversible bronchospasm with inflammation; common across all ages; a silent chest in a known asthmatic is ominous because too little air is moving to wheeze.
- Chronic obstructive pulmonary disease (COPD) — chronic bronchitis and/or emphysema, usually older patients with a smoking history. Provide oxygen to treat hypoxia; do not withhold needed oxygen out of fear of suppressing respiratory drive — hypoxia kills first.
- AEMT treatment — oxygen titrated to need, position of comfort, and nebulized albuterol for bronchospasm; CPAP for severe COPD distress when criteria are met.
Acute Pulmonary Edema (Cardiogenic)
Left-heart failure backs fluid into the alveoli.
- Findings — severe dyspnea, crackles/rales, frothy or pink-tinged sputum, often sitting upright and diaphoretic, possibly hypertensive.
- AEMT treatment — high-flow oxygen, upright positioning, and CPAP when criteria are met; albuterol does not treat fluid and is not the primary therapy. Definitive medications (e.g., nitrates) exceed AEMT scope and are paramedic-level.
Anaphylaxis-Related Airway Compromise
Anaphylaxis is a life-threatening systemic allergic reaction that can close the airway within minutes.
- Airway findings — stridor, hoarseness, lip/tongue/throat swelling, wheezing, plus hypotension, hives, and gastrointestinal symptoms.
- AEMT treatment — intramuscular (IM) epinephrine (autoinjector or AEMT-protocol IM dose) into the lateral thigh is the priority drug, plus high-flow oxygen, aggressive airway management, and rapid transport. Albuterol can be added for bronchospasm but does not replace epinephrine.
AEMT Respiratory Pharmacology
| Drug | Indication | AEMT Route | Key Point |
|---|---|---|---|
| Oxygen | Hypoxia, respiratory distress/failure | Inhalation / BVM | Titrate to adequate SpO2; do not withhold in hypoxic COPD |
| Albuterol | Bronchospasm (asthma, COPD) | Nebulized / metered-dose inhaler | Beta-2 agonist; side effects include tachycardia and tremor |
| Epinephrine (IM) | Anaphylaxis | Intramuscular (lateral thigh) | First-line, time-critical; reassess and prepare to repeat per protocol |
AEMT scope is set by state and medical-direction protocols; always follow local protocol, but these are the commonly tested AEMT respiratory medications.
Pediatric Airway Differences
Children are not small adults; airway anatomy and compensation differ.
- Larger tongue and head relative to the airway, so positioning is more easily lost.
- Narrowest point is the cricoid cartilage (not the cords as in adults).
- Smaller diameter airways mean small amounts of swelling or secretions cause large resistance increases.
- Higher metabolic demand and lower reserve — children desaturate quickly and bradycardia is a late, ominous sign of hypoxia.
- Early failure signs — nasal flaring, grunting, intercostal/subcostal retractions, head bobbing in infants, and a rising then falling respiratory rate as the child tires.
- Effective BVM ventilation is the cornerstone of pediatric respiratory failure care; correct mask size and gentle, chest-rise-titrated volumes are critical.
A known asthmatic in severe distress was loudly wheezing on arrival. A few minutes later the chest is now quiet with minimal air movement and the patient is becoming drowsy. What does this change indicate?
An AEMT treats a patient with severe dyspnea, crackles in both lung bases, pink frothy sputum, and a history of heart failure. Which intervention is most appropriate within AEMT scope?
A patient who ate shellfish develops hives, lip and tongue swelling, audible stridor, wheezing, and hypotension. What is the priority AEMT pharmacologic intervention?
Which statement about pediatric airway anatomy and respiratory emergencies is correct?