RESPIRATORY DISTRESS - ADULT

Inclusion Criteria:  Patients complaining of shortness of breath or those who have labored respirations, dyspnea, wheezing, or rales. Respiratory distress can be caused by a number of conditions, including asthma, airway obstruction, and volume overload (as in congestive heart failure (CHF) and end stage renal disease).  Treat patients with respiratory distress caused by trauma using the TRAUMA Guidelines and patients experiencing an allergic reaction using the ALLERGIC REACTION Guidelines.

Click here for the Respiratory Distress - Pediatric Guideline

SPECIAL NOTE:  If fever is present, along with any respiratory signs or symptoms, or if the patient is coughing, sneezing, or generating airborne droplets, EMS personnel should wear a HEPA mask to reduce transmission of infection.  A HEPA mask may be placed on the patient (if tolerated), or a 100% NRB mask may be used, if tolerated, to reduce transmission of infection.

Basic Level

1. Assess and support ABCs.
2. Place the patient in a position of comfort.
3. Administer oxygen, as needed, to maintain a SpO2 of at least 94%

1. Exception – COPD with chronic hypoxia (home O2 therapy): titrate oxygen flow to maintain SpO2 90%:
1. Observe for depressed ventilation, increased ETCO2 and decreased level of consciousness
2. If ETCO2 level rises in response to oxygen therapy, consider decreasing the concentration of supplemental oxygen.
4. If the patient is wheezing, administer albuterol 2.5 mg via nebulizer every 5 minutes up to 3 total doses.

Advanced Level

5. All patients treated under this guideline must have continuous ECG and ETCO2 monitoring.  If a dysrhythmia develops, treat under its specific guideline.  Anticipate the need for a possible advanced airway (ET tube or SGA) using PHARMACOLOGICALLY-ASSISTED INTUBATIONor awake NASOTRACHEAL INTUBATION.
6. Establish IV/IO access at a TKO rate or use a saline lock.
7. Assess breath sounds:
   1. Signs of volume overload (rales, JVD, or peripheral edema):
      
      
      • Nitroglycerin 0.4 mg SL (may administer without IV/IO if SBP is at least 90 mmHg).
      • May repeat twice, but only if SBP remains above 90 mm Hg.
      • If no significant improvement following NTG therapy, apply CPAP at 5 cm H2O pressure, if available.
        • In severe distress, paramedics may apply CPAP with the initial nitroglycerin therapy.
        • If no improvement and the patient is tolerating CPAP, increase CPAP pressure to 10 cm H2O, if available. •
      • If wheezing is also present, BioTel may authorize albuterol.
      • Obtain a 12-Lead ECG and consult with BioTel, as needed

b.  Wheezing:

• Mild to moderate wheezing, administer nebulized albuterol 2.5 mg:
  
  If wheezing persists but the patient is:
  • Improving, administer up to two additional albuterol doses.
  • Not improving with the first albuterol dose, combine 2nd and 3rd albuterol doses with ipratropium 0.5 mg (ipratropium dose for infant less than 1 year of age is 0.25 mg).

IIf no significant improvement following nebulizer therapy:

• Apply CPAP at 5 cm H2O pressure, if available:
  
  If the distress does not improve and the patient is tolerating CPAP, increase CPAP pressure to 10 cm H2O, if available.

If no significant improvement following application of CPAP, simultaneously:

• Administer methylprednisolone 60-125 mg IV/IO/IM (optional medication); AND
• Add 2 grams magnesium sulfate to 250 mL Normal Saline and infuse IVPB over 20 minutes:
  • Dialysis patient: BioTel must authorize.

If no response to nebulizers, CPAP or magnesium sulfate, with impending respiratory failure, administer:

• 1:1,000 Epinephrine 0.3 – 0.5 mg IM (0.3 to 0.5 mL IM).

c.  For status asthmaticus, simultaneously:

• Administer albuterol 2.5 mg with ipratropium 0.5 mg every five minutes, up to 3 doses.
• Administer 1:1,000 Epinephrine 0.3 – 0.5 mg IM (0.3 to 0.5 mL) (if not already done).
• Apply CPAP at 5 cm H2O pressure, if available:
  • If the distress does not improve and the patient is tolerating CPAP, increase CPAP pressure to 10 cm H2O
• Administer methylprednisolone 60-125 mg IV/IO/IM (optional medication); AND
• Add 2 grams magnesium sulfate to 250 mL Normal Saline and infuse IV piggyback over 20 minutes (if not already done):
  • BioTel authorization is required for patients on dialysis;
  • Avoid if history of COPD.

8. For additional patient care considerations not covered under standing orders, consult BioTel.