The Approach To Respiratory Distress
Edited By: Lorraine Thibodeau
Albany Medical Center, Albany, New York
"I can't breathe!"
A 68 year old man presents to the emergency department via ambulance complaining that he is unable to breathe. His vital signs are: BP = 190/90, P = 120, RR = 30, T = 98.8oF, O2 sat 90%.
The paramedics wheel him into the station and move him onto the stretcher with you right behind them...
In the emergency department, diagnosing the cause of respiratory distress occurs in concert with treatment. Rapid decisions must be made with limited information or your patient can decompensate in front of you.
Objectives
Upon completion of this self-study module, you should be able to:
- List the life-threatening causes of respiratory distress
- Describe the initial approach to a patient with respiratory distress
- Discuss the initial management plan for a patient respiratory distress
Initial Actions
The paramedics are putting their gurney away to leave. You are standing in front of the patient with a nurse at your side. The patient is breathing fast and doesn't look like he is up for a long conversation. What actions should you take immediately to help your patient?
- Oxygen
- Monitor and pulse oximeter
- Intravenous access
- Order an EKG and chest x-ray
- Get information from the paramedics
| Device | FiO2 |
|---|---|
| Nasal cannula at 2-3 L/min | 26% |
| Non rebreather at 15 L/min | 40-60% |
| Bag valve mask at 15 L/min | 90% |
Placing a nasal cannula
(click image to play video)
When faced with a patient in respiratory distress, remember "IV, O2, monitor" to get you started. Oxygen may have been initiated by the paramedics. If not, it should be applied in ED in the form of a non-rebreather or nasal cannula (Video 1 and Figures 1 and 2). Make sure you to have a brief conversation with the paramedics regarding the patient's current condition, past medical history, and medications before they leave. This information is frequently invaluable. While the nurse hooks the patient to the monitor and establishes an IV, have a few words with the patient and listen to their breathe sounds. Depending on how your patient looks and feels, consider that BiPap or endotracheal intubation may be necessary in the not too distant future if he doesn't turn around with your initial treatments.
Here is a video of the preparation for intubation.
Differential Diagnosis
Having a wide differential diagnosis list for respiratory distress before this patient rolls in the door will allow you to sort through the possible causes more rapidly. When faced with respiratory distress, all causes are potentially life-threatening.
Respiratory Distress Critical Diagnoses
The diagnoses you must consider in patients with an acute onset of respiratory distress include:
- Asthma/COPD exacerbation
- Acute coronary syndrome
- Pulmonary edema
- Pneumonia
- Pulmonary Embolism
- Tension Pneumothorax
- Pericardial tamponade
- Anaphylaxis
- Upper airway obstruction
Other causes of shortness of breath such as anemia, neuromuscular disorders, carbon monoxide poisoning should be considered and excluded, but the causes listed above are critical because they are common or immediately treatable.
The following sections on the specific differential diagnoses will list the specific details you should be looking for on your secondary survey and guide your choices for diagnostic testing and treatment.
Your Case
"I can't breathe!"
The patient is awake, but only able to string a few words together before he needs to take another breathe. The non-rebreather seems to be helping some and you aren't quite ready to set up for intubation just yet. The nurse establishes an antecubital intravenous line and the monitor reveals sinus tachycardia. The paramedics are able to report that the patient has COPD and congestive heart failure. You listen to his lungs and hear diffuse wheezing. Within a minute you have rapidly assessed the patient and are ready to start making some treatment decisions.