Respiratory

2-8-a. Respiratory Failure

This SO applies in cases of either impending respiratory arrest or respiratory arrest as shown by:

1) Inability to maintain O2 saturation ≤ 90% mmHg.

2) Respiratory rate < 6 breaths per minute.

3) Extreme work of breathing.

Where a pulse exists:

1) Do POX and ETCO2

2) Provide rescue breathing by assisted bag-valve mask / BVM ventilation with O2. If patient continues to deteriorate perform tracheal intubation.

3) If unable to intubate successfully, perform the alternate airway management and respiratory support.

a) Secure airway with supraglottic airway / SGA or

b) Continue assisted ventilations with BVM with supplemental O2 Establish IV NS at TKO, if not already done.

c) Perform RSI

2-8-b. Bronchospasm

1) Administer O2

2) Administer inhalation aerosol Duo-Neb treatment: Add Albuterol 5 mg and Ipratropium 0.5 mg into nebulizer.

3) If initial treatment is insufficient, may repeat Duo-Neb treatments X 2.

4) If no response to first nebulizer treatment in the setting of a patient’s history of CHF, or if pulmonary edema is suspected on examination, do not just repeat the nebulizer

5) If severely ill and no response to nebulizer treatments, consider:

a) Epinephrine 0.3 mg 1:1,000 IM

b) Magnesium Sulfate 2 gm IV slow drip over 10 minutes

c) Epinephrine (1 mg mixed into 1,000 ml NS = 1 mcg/1 ml) IV drip 1 ml per minute

6) If a patient with severe bronchospasm requires tracheal intubation and is still hard to ventilate because of the bronchospasm, use the Permissive Hypercapnea approach, with gentle BVM bagging and a very slow BVM rate (8 per minute), with moderate tidal volume (6 cc/kg).

2-8-c. Dyspnea

1) Administer O2

2) If CHF or pulmonary edema is suspected [see 2- 1-c. Congestive Heart Failure and Pulmonary Edema].

3) If indicated, apply Continuous Positive Airway Pressure / CPAP

2-8-d. Pneumothorax

Be aware that pneumothorax may be a cause of dyspnea, and it can also be an effect of our treatment, so avoid aggressive, high pressure ventilation with BVM or mechanical ventilator. Re-examine chest frequently and if needed, consider Needle Thoracostomy [see 1-11. Needle Thoracostomy].

2-8-e. Pulmonary Edema / Congestive Heart Failure

For patient with dyspnea and rales present in both lungs, with the absence of fever [see 2-1-c. Congestive Heart Failure and Pulmonary Edema].