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Respiratory Distress Protocol

HIGH PRIORITY

Systematic approach to assessment and management of acute respiratory distress

Severity Assessment

mild Distress

  • •RR 20-24
  • •SpO2 >92% on RA
  • •Speaking full sentences
  • •No accessory muscle use

moderate Distress

  • •RR 25-30
  • •SpO2 88-92%
  • •Speaking phrases only
  • •Some accessory muscle use

severe Distress

  • •RR >30 or <8
  • •SpO2 <88%
  • •Single words only
  • •Marked accessory muscle use
  • •Altered mental status

Initial Interventions

Key Physical Exam

Inspection

  • • Work of breathing
  • • Accessory muscle use
  • • Cyanosis
  • • Chest wall movement

Auscultation

  • • Wheezes (obstruction)
  • • Crackles (fluid/infection)
  • • Decreased (pneumothorax/effusion)
  • • Stridor (upper airway)

Percussion

  • • Hyperresonance (pneumothorax)
  • • Dullness (consolidation/effusion)

Red Flags

  • • Tracheal deviation
  • • Subcutaneous emphysema
  • • Paradoxical breathing
  • • Silent chest

Target Parameters

Oxygenation Goals

• SpO2: 92-96% (88-92% if COPD)

• PaO2: >60 mmHg

• P/F ratio: >300 (normal)

Ventilation Goals

• RR: 12-20/min

• PaCO2: 35-45 mmHg

• pH: 7.35-7.45

Work of Breathing

• No accessory muscle use

• Speaking full sentences

• RR <25/min

Oxygen Delivery Devices

DeviceFlow RateFiO2Indication
Nasal Cannula1-6 L/min24-44%Mild hypoxia
Simple Mask6-10 L/min40-60%Moderate hypoxia
Non-Rebreather10-15 L/min60-100%Severe hypoxia
High-Flow NCUp to 60 L/min21-100%Hypoxia with work of breathing
BiPAPVariable21-100%CHF, COPD, avoiding intubation
Mechanical VentilationVariable21-100%Respiratory failure

Differential Diagnosis

Asthma/COPD Exacerbation

Key Symptoms

Wheezing
Prolonged expiration
Accessory muscle use
History of asthma/COPD

Treatment

  • •Bronchodilators
  • •Steroids
  • •Magnesium
  • •Consider BiPAP

Pneumonia

Key Symptoms

Fever
Productive cough
Crackles
Pleuritic pain

Treatment

  • •Antibiotics
  • •Oxygen
  • •Fluids
  • •Antipyretics

Pulmonary Embolism

Key Symptoms

Sudden onset
Pleuritic pain
Hemoptysis
Risk factors

Treatment

  • •Anticoagulation
  • •Oxygen
  • •Consider thrombolysis if massive

Congestive Heart Failure

Key Symptoms

Orthopnea
PND
Bilateral crackles
JVD
Edema

Treatment

  • •Nitrates
  • •Diuretics
  • •BiPAP
  • •Position upright

Pneumothorax

Key Symptoms

Sudden onset
Decreased breath sounds
Hyperresonance
Tracheal deviation if tension

Treatment

  • •Oxygen
  • •Needle decompression if tension
  • •Chest tube

Anaphylaxis

Key Symptoms

Urticaria
Angioedema
Stridor
Hypotension

Treatment

  • •Epinephrine IM
  • •Antihistamines
  • •Steroids
  • •Fluids

Bronchodilators

Albuterol

2.5-5mg nebulized q20min x3

Bronchospasm

Ipratropium

0.5mg nebulized q20min x3

COPD, severe asthma

Epinephrine

0.3-0.5mg IM

Anaphylaxis, severe asthma

Steroids

Methylprednisolone

125mg IV

Asthma/COPD exacerbation

Prednisone

40-60mg PO

Mild-moderate exacerbation

Dexamethasone

10mg IV/IM

Alternative to methylpred

Other

Magnesium Sulfate

2g IV over 20min

Severe asthma

Furosemide

40-80mg IV

CHF/pulmonary edema

Nitroglycerin

0.4mg SL q5min

CHF with hypertension