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    Bedside emergency: Respiratory distress

    Our series on bedside emergencies continues this month with advice about assessment techniques, airway stabilization and management, and the importance of patient education.

    CE Center

    RN/AHC Media Home Study Program
    CE CENTER

    CE credit is no longer available for this article. (Expired July 2009)


    Originally Posted July 2007

    By SALLY BEATTIE, RN, MS, CNS, GNP

    SALLY BEATTIE is clinic manager at University of Missouri Hospital and Clinics in Columbia, MO, and a member of the RN editorial board. The author has no financial relationships to disclose.

    Our series on bedside emergencies continues this month with advice about assessment techniques, airway stabilization and management, and the importance of patient education.

    Acute respiratory distress is a frightening situation for patient and nurse alike. Suddenly and without warning, your patient is fighting to breathe. Though there may be no obvious clue as to why he's having difficulty, you know you must act quickly. Without adequate oxygen, his vital organs, especially the brain, will begin to die in a matter of minutes.

    As the acuity, age, and morbidity of hospitalized patients continue to increase, nurses need always be on the alert for this scenario.1 Here, we review what you need to know and do when confronted with this bedside emergency. We also examine the most common causes of acute respiratory distress, so that you'll recognize which of your patients may be at greatest risk.

    Calm the patient and call for help

    When you encounter a patient who's having difficulty breathing, reassure him that you're there to help. Stay in the room as you call for assistance and emergency equipment, and have someone notify the physician. Make sure you have an oral airway, oxygen, and a working suction set-up on hand, since the patient's condition could rapidly deteriorate and progress to cardiopulmonary arrest.

    Quickly determine whether the upper airway is patent.1,2 A partial obstruction may result in air hunger, while a more severe obstruction can lead to cyanosis, confusion, or unconsciousness. Complete obstruction, if not corrected, can progress to rapid suffocation and death.

    With a partial obstruction, there are no signs of cyanosis and the patient may be able to respond verbally, albeit weakly. He may have the strength to produce a forceful cough, in which case you shouldn't interfere with his efforts. If the culprit is a lodged object, piece of food, or mucous plug, the patient may be able to eject it on his own.

    You'll have to intervene at once, however, if the airway is completely blocked, or if signs of severe obstruction are present.2 You can quickly verify this by asking, 'Are you choking?' If the patient is unable to speak but gestures 'Yes' by nodding or by clutching his throat—the universal distress signal for a blocked airway—he has severe obstruction. Other signs include a weak cough that becomes silent, cyanosis above the neck, and labored breathing that produces a high-pitched noise.1,2

    Act quickly to clear a blockage

    If you suspect upper airway obstruction, perform the Heimlich maneuver. Here's a review: With a patient who is standing or sitting, encircle his waist with your arms from behind, and make a fist with one hand. Place your fist with the thumb side against the middle of his abdomen, slightly above the navel but well below the xiphoid process. With your free hand, grasp your fist, press it into the abdomen, and apply six to 10 quick upward thrusts.

    Should you be unable to get your arms around the patient, move him onto his back—with help, if needed. If he's already lying in bed, roll him on his side, place a board under his back, and turn him so that he's supine. Kneel astride his thighs and place the heel of one hand on his abdomen, in the same location you'd place your fist if the patient were upright. Put your other hand directly on top of that one, and deliver six to 10 quick upward thrusts. Repeat as needed.3

    If the patient is obese or becomes unconscious, bend the chin forward and make sure his tongue isn't blocking the airway. You should apply chest compressions, placing your hands as you would to perform cardiopulmonary resuscitation. Give a series of sharp compressions. If performing these maneuvers correctly doesn't work, be prepared to assist with emergency tracheostomy or endotracheal intubation.2

    Obstruction caused by spasm and edema

    More often than not, you'll encounter a patient whose upper or lower airways are obstructed by airway spasm or edema. Tightening of the larynx (laryngospasm) and/or bronchioles (bronchospasm), along with edema, are part of the inflammatory response. Symptoms range from mild to severe. The causes are many and include irritants such as smoke or other toxic fumes, viruses or bacteria, trauma or surgery, aspiration, and even certain medications like pilocarpine (Salagen) or anesthetics.

    For instance, epiglottitis is inflammation of the epiglottis, often brought on by a viral infection that can rapidly become life threatening. A patient will suddenly sit up straight, tip his head forward, and hold very still just to breathe better. When swollen, the epiglottis causes a crowing sound, called inspiratory stridor, as the airway becomes progressively obstructed. The patient's voice may become muffled, and he may drool because he can't swallow. In severe cases, the patient may be cyanotic.

    For acute epiglottitis, you have to act quickly: Reassure the patient, and call for help and emergency airway equipment. You may need to bag the patient, or apply high-flow oxygen by face mask until he can be intubated. But be prepared to assist with cricothyroidotomy or tracheostomy if intubation isn't possible.

    While your unit may never see a case of epiglottitis, you'll likely encounter patients with obstructed airways from an exacerbation of COPD or asthma, anaphylaxis, pulmonary edema, or severe bronchitis, pneumonia, or acute respiratory distress syndrome (ARDS). In these cases, the patient may have stridor from laryngoedema or wheezing, or both, and may be coughing up clear, pink, or purulent secretions. Knowing what to do in the immediate crisis can help you stabilize the patient, find the cause of the respiratory difficulty, and ward off respiratory failure.

    Managing respiratory failure

    When your patient is headed for respiratory failure, you'll aggressively support oxygenation until the underlying condition is determined and resolved. You'll likely provide oxygen by face mask, a Venti, or 100% non-rebreather mask to maintain PaO2 above 60 mm Hg. If hypoxia persists, intubation and mechanical ventilation may be necessary, or a non-invasive mode of ventilation assistance may be used. Also be prepared to administer bronchodilators and mucolytic agents, and to suction the patient as needed, to improve oxygenation.

    Your patient is in acute respiratory failure if his PaO2 is below 60 mm Hg and his PaCO2 is above 50 mm Hg. Depending on the cause, failure can occur in minutes.4,5 For additional signs and symptoms, see the box on this page.

    Watch for failing organs

    Every organ and tissue in the body depends on oxygen to maintain function. So when the oxygen-carbon dioxide exchange is impaired, organs will start to fail, beginning with the lungs. In such scenarios, you'll observe for signs of hypoxemia (decreased blood oxygen) and hypoxia (decreased tissue oxygen). Early signs include restlessness, anxiety, tachycardia, and tachypnea.

    Without intervention, your patient may develop decreased cardiac function and dysrhythmias from acidemia; worsening of dyspnea and an increase in the work of breathing; decreased urine output that can signal the onset of kidney failure; and decreased bowel sounds that may indicate ischemic bowel.

    Ways to reduce patient anxiety

    The severity of acute respiratory failure can increase when the patient becomes anxious, which is common when someone experiences severe dyspnea and hypoxemia. Anxiety and fear will increase oxygen demand and the work of breathing, further compromising oxygen availability for crucial organ function, and depleting respiratory muscle strength.

    To reduce anxiety, maintain a supportive environment and briefly explain to the patient and family what's being done to relieve the condition. Respiratory failure leads to a buildup of acid in the blood, which causes and perpetuates the anxiety from air hunger.

    If the patient is not on a ventilator, you can try having him take deep breaths (as outlined below) to increase gas exchange, which will decrease anxiety.4 The physician may order anxiolytics, such as lorazepam (Ativan), in mild doses to avoid depressing respiration. She may also give a small dose of morphine, which will relieve anxiety and reduce the pulmonary congestion by unloading the heart.

    Assess for clues to find the cause

    Additional treatment will depend on the cause of the respiratory distress. Review the patient's history for risk factors, the most common of which are listed in the box above.

    Your physical assessment will help pinpoint the precipitating event. Although the possibilities are numerous, acute onset of respiratory distress is frequently caused by:

    Pulmonary embolism (PE). When a clot has occluded one of the pulmonary vessels, you may note crackles (rales), wheezing, a pleural rub, or decreased breath sounds in the affected area. The patient may complain of sharp pain that worsens when he takes a deep breath, or chest wall tenderness. A large PE may produce hemoptysis.6,7 Besides tachycardia, you may hear a new S3 or S4 gallop when listening to heart sounds. The EKG may show depressed ST segments, a right bundle-branch block, or atrial fibrillation.6

    In addition to oxygen, a rapidly acting fibrinolytic agent is usually administered immediately as a bolus, and heparin is given to slow or prevent clot progression and reduce the risk of further embolism.7

    Pneumothorax. A patient with air in the pleural space will have breath sounds that are decreased or absent in the area where the lung has collapsed. He may also complain of chest pain on that side.8 If the problem is a tension pneumothorax, with air leaking into the pleural space through a tear in the lung, you may also hear ipsilateral crackles or wheezes. Muffled heart sounds, pulsus paradoxus (a significant drop in BP on inspiration that weakens the radial pulse), and jugular venous distension may also be apparent. Pneumothorax is potentially life threatening, so be prepared to assist with chest tube insertion.2,9

    Acute asthma attack. During an exacerbation of asthma, the airways are inflamed and constricted, producing, in most cases, wheezing on expiration. You may also observe a decrease in chest wall expansion during inhalation. Be aware that although wheezing is a common finding, its severity doesn't correspond to the degree of airway resistance. In fact, the absence of wheezing during an asthma attack may indicate a critical, life-threatening situation. If asthma is the cause of your patient's respiratory distress, be ready to administer steroids and inhaled bronchodilators, in addition to oxygen.2,6

    Acute (flash) pulmonary edema. 'The quick buildup of fluid in the lungs typically produces bilateral crackles, as air passes through the fluid-filled alveoli. Also observe for the presence or absence of distended neck veins. The patient may cough up frothy, often pink-tinged, secretions.

    Watch the EKG for a change in heart rate or rhythm, such as atrial fibrillation or bradycardia. Cardinal EKG signs of acute coronary syndrome—ST segment elevation or depression—may also be evident, since pulmonary edema is most frequently associated with MI or left ventricular heart failure. For pulmonary edema, be prepared to administer furosemide (Lasix) IV push, but don't give more than 20 mg/minute.

    Acute respiratory distress syndrome (ARDS). One of the most lethal of the syndromes that lead to respiratory failure, ARDS is characterized by noncardiac pulmonary edema caused by increased alveolar capillary membrane permeability.4 Copious secretions, along with crackles or wheezes, will be present; so will dyspnea, tachypnea, and intercostal retractions.

    Much of the management of ARDS relies on mechanical ventilation with positive end-expiratory pressure, supportive care, and the prevention of complications. There are no known interventions to limit the disease progression or reverse the underlying structural defects.4

    A watchful eye is needed afterward

    Whatever the underlying cause of respiratory distress may be, as your patient is being stabilized, assess his response to treatment and your interventions. Monitor his vital signs, and pay particular attention to his blood gas results. Be on the alert for signs of recurrent hypoxia, and make sure the oxygen delivery system you're using is applied and working correctly. Keep in mind that mechanical intervention may be necessary.

    Review the management plan and its contingencies with the physician so you'll be able to anticipate what's needed and be ready to intervene. Provide ongoing emotional support and explanations to the patient as he recovers from this frightening experience, and include the family in your care as well.

    When appropriate, teach your patient diaphragmatic breathing to slow the rate and increase the depth of his respirations.4 Place one hand on his abdomen. Instruct him to inhale deeply, and during exhalation, to let his belly sink down toward the spine. Make sure the patient notices how your hand moves up and down on his belly. Explain that his chest shouldn't be moving at all. After a minute or two, ask him to place his own hands on his belly to continue the exercise. Patients with emphysema should hold the inhalation for two or three seconds, if possible, to increase gas exchange at the alveoli, and then exhale as if blowing kisses to slow down the rate.

    Keep the situation from worsening

    Respiratory distress can precede full-blown cardiopulmonary arrest, a challenge for even the most experienced nurse. With your knowledge and fine-tuned assessment skills, you can help identify the cause of your patient's breathing difficulty, intervene quickly and appropriately, and perhaps reverse the course of clinical deterioration.


    REFERENCES

    1. Lilly, C., Ingenito, E. P., & Shapiro, S. D. (2005). Respiratory failure. In D. L. Kasper, E. Braunwald, et al. (Eds.). Harrison's principles of internal medicine (16th ed.), (pp. 1588 – 1591). New York: McGraw-Hill.

    2. American Heart Association. '2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 4: Adult basic life support.' 2005. http://circ.aha journals.org/cgi/reprint/112/24_suppl/IV-19 (4 May 2007).

    3. Heimlich Institute. 'How to do the Heimlich maneuver.' 2006. www.heimlichinstitute.org/page.php?id=34 (4 May 2007).

    4. Chulay, M. (2006). Respiratory system. In M. Chulay & S. M. Burns. AACN essentials of critical care nursing (pp. 247 – 266). New York: McGraw-Hill.

    5. Sharma, S. 'Respiratory failure.' 2006. www.emedicine.com/med/topic2011.htm (1 May 2007).

    6. Diepenbrock, N. H. (2004). Quick reference to critical care (2nd ed.), (p. 164). Philadelphia: Lippincott Williams & Wilkins.

    7. Feied, C. 'Pulmonary embolism.' 2006. www.emedicine.com/EMERG/topic490.htm (4 May 2007).

    8. Chang, A. K., & Barton, E. D. 'Pneumothorax, iatrogenic, spontaneous and pneumomediastinum.' 2005. www.emedicine.com/emerg/topic469.htm (4 May 2005).

    9. Bowman, J. G. 'Pneumothorax, tension and traumatic.' 2006. www.emedicine.com/EMERG/topic470.htm (4 May 2007).


    Signs and symptoms of respiratory failure

    • Hypoxemia (PaO2 <60 mm Hg)
    • Restlessness
    • Tachypnea
    • Dyspnea
    • Tachycardia
    • Confusion
    • Diaphoresis
    • Anxiety
    • Hypercapnia (PaCO2 >50 mm Hg)
    • Hypertension
    • Irritability
    • Somnolence (late)
    • Cyanosis (late)
    • Loss of consciousness (late)
    • Pallor
    • Use of accessory muscles of respiration
    • Abnormal breath sounds (crackles, wheezes)

    Sources: 1. Chulay, M. (2006). Respiratory system. In M. Chulay & S. M. Burns. AACN essentials of critical care nursing. (pp. 247 – 266). New York: McGraw-Hill. 2. The Merck Manuals. 'Respiratory failure.' 2003. www.merck.com/mmhe/sec04/ch055/ch055a.html# (26 Apr. 2007).


    Common factors that precipitate acute respiratory distress

    • Acute infection, particularly bronchitis/pneumonia
    • Asthma
    • COPD
    • Heart disease
    • Neuromuscular disease
    • Pilocarpine medications (some)
    • Pulmonary edema
    • Pulmonary embolism
    • Pneumothorax
    • Trauma
    Source: Sharma, S. 'Respiratory failure.' 2006. www.emedicine.com/med/topic2011.htm (4 June 2007).

    Free DVD Provides Respiratory Training

    A free DVD that trains health professionals who are not respiratory specialists to provide respiratory care and ventilator management during public health emergencies is now available through the federal Agency for Healthcare Research and Quality (AHRQ).

    The DVD, ?Cross Training Respiratory Extenders for Medical Emergencies (Project XTREME)? is intended to prepare nurses, physicians, and physician assistants for an influenza pandemic, a bioterrorist attack involving anthrax or other agents, or an outbreak of severe acute respiratory illnesses.

    AHRQ said the DVD isn't intended to train professionals to become respiratory therapists, but to expand medical resources during emergencies. Order a copy of the DVD, with six training modules, by calling (800) 358-9295 or e-mailing [email protected].

    Sally Beattie, RN, MS, CNS, GNP
    Sally Beattie, is an RN editorial board member and an advanced practice nurse at the University of Missouri Hospital and Clinics, ...