Respiratory Distress / Failure¶
Category: Medical Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf Last updated: 2026-05-06 Sources: raw/protocols/nm-sop-guidelines-treatment-2022.pdf; UCLA EMT Ultimate Study Guide (2026)
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
NREMT Differentiators¶
Distress vs. Failure¶
| Finding | Respiratory Distress | Respiratory Failure |
|---|---|---|
| Mental Status | Alert, anxious | Confused, lethargic, unresponsive |
| Speech | 2–3 word dyspnea | Unable to speak |
| Rate | Tachypnea | <10 or >30; gasping; agonal |
| Chest Rise | Present | Poor or absent |
| SpO2 | May still be >94% | Dropping despite O2 |
| Skin | Diaphoretic, flushed | Cyanotic |
| Treatment | O2 — NC (1–6 LPM) or NRB (10–15 LPM) | BVM @ 15 LPM with O2 |
KEY DIFFERENTIATOR: The mental status IS the differentiator. ALERT + struggling = distress (O2). ALTERED or cyanotic = failure (BVM). Never give O2 when BVM is needed.
Croup vs. Epiglottitis¶
| Feature | Croup | Epiglottitis |
|---|---|---|
| Onset | Gradual | SUDDEN |
| Cough | Seal-bark, inspiratory stridor | No cough — can't swallow |
| Fever | Low-grade | HIGH (>102°F) |
| Drooling | No | YES (can't swallow) |
| Position | Any | Tripod (leaning forward) |
| Voice | Hoarse | Muffled "hot potato" |
| Age | 6 months–3 years | Any age |
| Treatment | Humidified O2, calm child, nebulized Epi (ALS) | DO NOT examine throat — transport immediately |
KEY DIFFERENTIATOR: Croup = barky cough + low fever + NO drooling + gradual onset. Epiglottitis = HIGH fever + DROOLING + tripod + SUDDEN onset. One tongue blade exam can precipitate complete airway obstruction in epiglottitis.
Asthma vs. COPD¶
| Feature | Asthma | COPD |
|---|---|---|
| Reversibility | Reversible, trigger-based | Chronic, irreversible |
| Age | Younger | Older, smoking history |
| Bronchitis subtype | N/A | Rhonchi + productive cough + "blue bloater" |
| Emphysema subtype | N/A | Crackles + pursed-lip breathing + barrel chest + "pink puffer" |
| O2 Target | 94–100% | 88–92% (hypoxic drive concern) |
| Silent chest | = no airflow = BVM situation | = no airflow = BVM situation |
NREMT TIP: Don't withhold O2 if they need it — just TITRATE. Never deny O2 to a hypoxic patient. Status asthmaticus = prolonged attack not responding to therapy → ALS immediately.
Lung Sound Quick Reference¶
| Sound | Cause | Conditions | Differentiator |
|---|---|---|---|
| Crackles/Rales | Fluid in alveoli | CHF, pneumonia, emphysema | Bilateral = CHF; Unilateral/localized = pneumonia |
| Rhonchi | Secretions in large airways | Chronic bronchitis, pneumonia | Gurgling/snoring quality; may clear with cough |
| Wheezes | Bronchospasm | Asthma, COPD, anaphylaxis | Expiratory > inspiratory; silent chest = severe |
| Stridor | Upper airway obstruction | Croup, epiglottitis, anaphylaxis | Inspiratory; high-pitched; UPPER airway problem |
| Absent (one side) | Collapsed/fluid-filled space | Pneumothorax, hemothorax | Critical finding — immediately investigate cause |
KEY DIFFERENTIATOR: Stridor = upper airway. Wheeze = lower airway. Never confuse — they need different treatments and have different causes.
PE vs. Pneumonia vs. CHF¶
| Feature | PE | Pneumonia | CHF |
|---|---|---|---|
| Lung Sounds | CLEAR | Localized crackles + fever | BILATERAL crackles |
| Onset | Sudden | Over days | Progressive |
| Key Finding | Sudden dyspnea + tachycardia + risk factors | Productive cough + fever | Orthopnea, PND, JVD, edema |
| Treatment | O2, rapid transport (cardiac emergency) | O2, transport for antibiotics | O2/CPAP, NTG (if SBP >100), upright position |
KEY DIFFERENTIATOR: PE = CLEAR lung sounds + sudden dyspnea in patient with risk factors (DVT, immobility, surgery, cancer). CHF = bilateral crackles vs. Pneumonia = UNILATERAL/localized + fever. The most-tested respiratory differentiator.
O2 Device Selection¶
| Device | Flow Rate | Approx. FiO2 | When to Use |
|---|---|---|---|
| Nasal Cannula (NC) | 1–6 LPM | 24–44% | Mild distress; COPD (titrate to SpO2 88–92%) |
| Non-Rebreather Mask (NRB) | 10–15 LPM | ~90% | Moderate-severe distress; any shock; CO poisoning |
| BVM | 15 LPM | ~100% with reservoir | Respiratory failure; cardiac arrest; rate <10 or >30 |
| CPAP | — | Variable | Awake, spontaneously breathing patient with CHF/COPD |
KEY DIFFERENTIATOR: CPAP is NOT a ventilation device. If the patient stops breathing while on CPAP → switch to BVM immediately.
Related¶
- bvm-ventilation — procedure details for BVM ventilation
- oxygen-administration — O2 delivery device selection and flow rates
- oxygen — pharmacology of oxygen
- anaphylaxis — respiratory distress from allergic reaction
- primary-assessment — breathing assessment drives the intervention decision
- acs-chest-pain — chest pain with respiratory distress (CHF/pulmonary edema)
- pediatric — Croup vs. Epiglottitis detail; PAT; pediatric-specific respiratory assessment
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)- UCLA EMT Ultimate Study Guide (2026) — Ch 2: Airway Management; Ch 5: Respiratory Emergencies