EMERGENCIES IN RESPIRATORY

MEDICINE
DR SOUTRIK DUTTA
SENIOR RESIDENT,
DEPARTMENT OF MEDICINE
Definition
Respiratory emergencies are medical
emergencies characterized by difficulty in
breathing or inability to breathe.
In such emergencies :
Patient take frequent shallow/irregular or
slow breaths
Immediate medical help/hospitalization
required
Patient is extremely agitated
Can be fatal, if not treated.
Physiology
Inspiration
Active process
Chest cavity expands
Intrathoracic pressure falls
Air flows in until pressure equalizes

Expiration
Passive process
Chest cavity size decreases
Intrathoracic pressure rises
Air flows out until pressure equalizes
Various Respiratory Emergencies are :-
1) Status Asthmaticus
2) Acute exacerbation of COPD
3) Acute Respiratory Distress Syndrome (ARDS)
4) Acute Pulmonary Edema
5) Acute Pulmonary Embolism
6) Pulmonary Hypertension in Newborn and Adults
7) Acute Mountain Sickness (AMS)
8) Tension Pneumothorax
9) Decompression Syndrome
10) Respiratory Acidosis
11) Acute Respiratory Failure
12) Aspiration Pneumonia
Status Asthmaticus (Severe Acute Asthma): Status
asthmaticus is severe, prolonged asthma exacerbation not
responding to usual doses of inhaled bronchodilators &
associated with symptoms of potential respiratory failure.
Sudden onset(resulting from spasm of airways) or may be
more insidious. Precipitated by viral respiratory infection /
prolonged exposure to allergen. Requires early recognition
and immediate treatment, if not danger of respiratory
failure.
Treatment 1) ABG analysis and SpO2 analysis done to find
out Oxygen saturation. 2) Oxygen (100%) given 2-4 l/min via
face mask. 3) Beta-adrenergic agonists – to relieve
bronchospasm
3) Anticholinergics 4) Corticosteroids
5) Aminophylline
6) Antibiotics
7) If patient is in severe acidosis – shift to ICU and ventilated
if needed.
8) ECG with 2 D-Echo if patient is in failure.
9) In severe spasm and respiratory failure, BiPAP given
Acute Exacerbation of COPD (Chronic Obstructive
Pulmonary Disease)
Emergency Care:
1. ABG analysis and SpO2 analysis done to find out Oxygen
saturation.
2. Position patient - sitting and loosen restrictive clothing
3. Assist ventilation if required and shift to intensive care
unit.
4. Oxygen therapy (100 %) to be titrated to improve
patients hypoxaemia with a target saturation of 88-92 %
then low flow oxygen given.
5. Bronchodilators Salbutamol & Ipratropium bromide
given in combination via nebulization
6. Corticosteroids Hydrocortisone
7. Antibiotics.
8. Lasix 40 mg IV stat given as single bolus dose imrpoving
biventricular failure.
9. If patient is having CO2 narcosis / Poor consciousness /
pH is 7.2 or less intubate patient. If pH > 7.2 BiPAP can
be given. If patient not improved with BiPAP, more
secretions & not tolerating then give mechanical
ventilation.
10. If severe bronchospasm – IV drip of magnesium 4 amp 2
gm
Acute Respiratory Distress Syndrome ( ARDS) 
Fulminant form of respiratory failure
characterized by acute lung inflammation and
diffuse alveolar-capillary injury.
Emergency Care: 1. Immediate hospitalization
along with 100 % high concentration oxygen
and ventilatory support. 2. Initial fluid
replacement to maintain cardiac output and
peripheral perfusion.
3 Surfactants. 4. Corticosteroids. 5.
Additionally patients should receive low
molecular-weight heparin. 6.Nutritional
support preferably enteral, within 24 to 48
hours of admission to ICU. 7. Surfaxin
(lucinactant) a synthetic formulation of
pulmonary surfactant is indicated for
prevention of RDS in infants. 8.
Higher antibiotics should be used as ARDS
occurring due to sepsis need effective
antibiotics like Piperacillin, Imepenum.
Acute Pulmonary Edema  It is a condition
caused by excess fluid in lungs with collection
of fluid in numerous air sacs making it difficult
to breathe. A medical emergency requiring
immediate care & if untreated leads to
respiratory failure.
Causes may be cardiac or non cardiac.
Treatment 1) Immediate hospitalization 2)
Place patient in position of comfort. Often
patient chooses to sit upright posture. 3)
Oxygen therapy 4) Monitor IV fluids and Blood
pressure changes. 5) Give Continuous Positive
Airway Pressure (CPAP)
7) Nitroglycerin sublingual 0.4 mg, can repeat
every 5 mins upto 3 doses if BP remains ≥ 100
mmHg. 8) Lasix 40 mg by IV infusion & repeat
dose if needed. 9) Morphine sulphate given 2
mg IV, titrate to response and vital signs,
repeated every 2 mins to a maximum of 10 mg.
Increases venous capacity and decrease
venous return to heart. 10) Albuterol 2.5 mg in
3ml solution is administered via nebulizer to
reverse bronchospasm.
Acute Pulmonary Embolism  It is a clot that
forms in the deep venous system, usually in
thigh or pelvis, breaks off and travels to lungs,
where it lodges in pulmonary vasculature.
Leads to hypoxemia and increase workload on
heart. Injury to blood vessels, decreased
venous blood flow and alterations in
coagulation system all increase risk of
pulmonary embolism. Signs & symptoms:
•Dypsnea/tachypnea •Cyanosis •Acute
pleuritic chest pain •Hemoptysis •Hypoxia
Emergency Care 1) Immediate hospitalization
and oxygen therapy (100 %) to all hypoxaemic
patients to restore arterial oxygen saturation to
over 90%. 2) Opiates (Morphine) 3) Obtain IV
access, monitor closely vital parameters
including Blood Pressure. Massive PE
suspected if there systolic BP <90 mmHg or
there is a fall of 40 mmHg for 15 mins not due
to other causes. 4) Anticoagulation – LMW
Heparin or Fondaparinux or Unfractioned
Heparin
5) Surgical Procedure – Embolectomy in
massive PE.
 Acute Mountain Sickness (AMS)  A syndrome
comprising headache (principal symptom)
together with fatigue, anorexia, nausea and
vomiting, difficulty sleeping and dizziness.
Ataxia and peripheral edema may be present.
Aetiology not clearly understood but though
that hypoxaemia increases cerebral blood flow
and hence intracranial pressure.  Symptoms
occur within 6-12 hours of an ascent and vary
in severity
Treatment : Rest & simple analgesia
Symptoms usually resolve after 1-3 days at a
stable altitude but may reoccur with further
ascent. Avoidance of over exertion at high
altitude. Supplementary oxygen can be given.
Descent the patient from high altitude.
Prophylactic Acetazolamide is the drug of
choice
 Dexamethasone
Nifedipine
(Beta-adrenergic agonists for bronchodilatory
action.
Phosphodiesterase-5 inhibitor like Sildenafil (5
– 20 mg TDS orally) to increase blood flow to
lungs.
NSAIDS and Anti-emetics when necessary.
Decompression Sickness  Most common in
Scuba Divers  Ambient pressure under water
increases by 101kPa (1atmp) for every 10 m of
sea water depth.
Management 1) Patient nursed in horizontal
position 2) Recompression requiring transfer of
patient to surface or air provided the altitude
remains low (<300 m) and patient continues to
breathe 100% oxygen. Recompression reduces
volume of gas within tissues & puts nitrogen
back into solution. 3) High flow oxygen to be
given by tight fitting mask. Assists in wash out
of excess inert gas & reduce extent of local
tissue hypoxia which can result from focal
embolic injury. 4) Neurological & pulmonary
symptoms, marked skin lesions to be treated
by hyperbaric oxygen(100 % Oxygen delivered
in high pressure chamber) if seen in 10-14
days. 5) Intravenous fluid replacement with 0.9
% saline or Hartmann’s solution to correct
intravascular fluid loss from endothelial bubble
injury & dehydration associated with
immersion.
 Tension Pneumothorax  Tension
pneumothorax is a complete collapse of the
lung. It occurs when air enters, but does not
leave, the space around the lung (pleural
space).
66.
Treatment 1) Immediate Hospitalization 2)
Main aim is to remove air from pleural space
allowing lung to re-expand. 3) In emergency, a
small needle (IV needle) is placed in chest
cavity through the ribs to relieve pressure. 4)
Standard treatment is a chest tube, a large
plastic tube is inserted through the chest wall
between 4th, 5th or 6th Intercostal space to
remove air. The chest tube is attached to a
vacuum bottle that slowly removes air from
the chest cavity. This allows the lung to re-
expand. As the lung heals and stops leaking air,
the vacuum is turned down and then the chest
tube is removed.
Aspiration Pneumonia  Aspiration
pneumonia is an inflammation of lungs and
bronchial tubes
Symptoms are cyanosis, shortness of breath,
chest pain, fever, coughing up foul sputum.
Bronchoscopy is helpful in diagnosing the
condition.
72.
Treatment 1) Immediate Hospitalization 2)
Oxygen supplementation, cardiac monitoring &
pulse oximetry. 3) Oropharyngeal / tracheal
suctioning may be indicated to further remove
aspirate. 4) Reassess the need for intubation
on frequent basis 5)IV fluids & electrolyte
replacement. 5) Bronchoscopy helpful when
aspiration of foreign body or food material
suspected, also helpful in guiding antibiotic
therapy.
Conclusion Every patient diagnosed with life
threatening respiratory emergency should
receive the emergency care as early as possible
including oxygenation, ventilatory support and
appropriate pharmacotherapy which would
help in saving patients life and preventing
complications.