Emergency Department: Respiratory Care and Management

The emergency department is a high-acuity setting where patients with sudden or potentially life-threatening cardiopulmonary problems must be evaluated and treated quickly.

Respiratory therapists play an important role in this environment because many emergencies involve airway obstruction, impaired ventilation, hypoxemia, respiratory failure, trauma, cardiac arrest, or worsening chronic lung disease.

Effective respiratory care in the emergency department depends on rapid assessment, early stabilization, appropriate use of oxygen and ventilatory support, timely medication delivery, and frequent reassessment to determine whether the patient is improving or deteriorating.

Role of the Respiratory Therapist in the Emergency Department

Respiratory therapists are often directly involved in the initial stabilization of patients who arrive with respiratory or cardiopulmonary emergencies. Their responsibilities vary according to the severity and cause of the patient’s condition, but commonly include airway assessment, oxygen administration, aerosolized medication delivery, manual ventilation, artificial airway management, arterial blood gas analysis, noninvasive ventilation, mechanical ventilation, and cardiopulmonary resuscitation.

Respiratory therapists also work as members of multidisciplinary emergency teams that may include physicians, nurses, paramedics, pharmacists, and other specialists. In many hospitals, they participate in rapid response teams and medical emergency teams that respond when hospitalized patients suddenly deteriorate.

During cardiac arrest or severe respiratory failure, respiratory therapists may assume responsibility for airway positioning, bag-mask ventilation, endotracheal intubation assistance, oxygen delivery, ventilator setup, airway suctioning, and confirmation of artificial airway placement. Their responsibilities may continue after spontaneous circulation has been restored.

The central goal is to recognize immediate threats to airway, breathing, and oxygenation and provide enough support to stabilize the patient while the underlying cause is identified and treated.

Initial Emergency Department Assessment

Emergency respiratory assessment begins as soon as the patient is encountered. Initial evaluation should emphasize the patient’s overall appearance and whether there is an immediate threat to life.

Important findings include:

• Respiratory rate and breathing pattern
• Heart rate
• Blood pressure
• Oxygen saturation
• Level of consciousness
• Skin color
• Work of breathing
• Use of accessory muscles
• Chest movement
• Breath sounds
• Ability to speak
• Presence of cough or secretions
• Signs of cyanosis
• Evidence of trauma

A patient who is severely dyspneic, confused, cyanotic, or unable to speak normally may require immediate intervention before a complete diagnostic evaluation can be performed. Treatment should never be delayed when an obvious life-threatening problem is present.

For example, a comatose patient rescued from a house fire should receive high-concentration oxygen as soon as airway patency has been confirmed. Pulse oximetry, arterial blood gas analysis, CO-oximetry, and chest imaging may still be necessary, but none should delay oxygen administration.

The same principle applies when a mechanically ventilated patient suddenly develops signs of ventilatory failure. If high-pressure and low-volume alarms occur simultaneously and the patient appears unstable, the therapist may need to disconnect the ventilator and manually ventilate the patient with 100% oxygen while the cause is investigated.

Airway Assessment

Maintaining a patent airway is one of the highest priorities in emergency respiratory care. Airway obstruction may result from trauma, secretions, foreign-body aspiration, swelling, loss of muscle tone, burns, blood, vomitus, or neurologic impairment.

Signs of significant airway obstruction may include stridor, snoring, gurgling, paradoxical chest movement, inability to speak, altered consciousness, cyanosis, and reduced or absent air movement.

Inspiratory stridor is especially important because it usually indicates upper-airway narrowing. Causes may include croup, epiglottitis, laryngeal edema, foreign-body aspiration, or airway trauma.

A patient with severe upper-airway obstruction may require placement of an artificial airway. Endotracheal intubation is generally preferred when possible, although severe airway injury may occasionally require an emergency surgical airway.

Cervical Spine Considerations

Airway management becomes more complicated when cervical spine injury is suspected. Trauma patients with possible spinal injury should be managed while maintaining cervical alignment.

The head and neck should not be hyperextended during airway positioning. Manual inline stabilization may be required during intubation. If the patient must be repositioned, a log-roll technique should be used so that the head, neck, and torso remain aligned.

Breathing and Ventilation Assessment

After airway patency has been established, ventilation and oxygenation should be evaluated.

Respiratory distress may appear as tachypnea, shallow breathing, prolonged expiration, accessory muscle use, nasal flaring, intercostal retractions, paradoxical breathing, diaphoresis, anxiety, cyanosis, or altered mental status.

Breath sounds can provide important clues. Wheezing commonly indicates airflow obstruction, while crackles may occur with pulmonary edema, pneumonia, or pulmonary contusion. Diminished or absent breath sounds may indicate severe obstruction, pneumothorax, pleural fluid, or reduced ventilation.

A reduction in wheezing should not automatically be interpreted as improvement. In severe asthma, wheezing may disappear because airflow has become critically reduced. If wheezing decreases while breath-sound intensity also decreases, airway obstruction may actually be worsening.

Note: Improvement is more likely when wheezing decreases while overall airflow and breath-sound intensity increase.

Pulse Oximetry and Oxygen Assessment

Pulse oximetry provides rapid information about arterial oxygen saturation and is useful for most emergency patients with suspected respiratory compromise. Unstable patients may require continuous monitoring.

Supplemental oxygen should be adjusted according to the patient’s oxygenation and overall clinical condition. Patients with severe trauma, respiratory failure, cardiac arrest, or significant hypoxemia may initially require high oxygen concentrations.

Pulse oximetry has important limitations, however. One of the most significant occurs in suspected carbon monoxide poisoning.

Standard pulse oximeters cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin. A patient with severe carbon monoxide exposure may therefore display a seemingly normal oxygen saturation despite serious impairment of oxygen transport. CO-oximetry should be used when carbon monoxide poisoning is suspected.

Arterial Blood Gas Analysis

Arterial blood gas testing may be necessary when information about oxygenation, ventilation, or acid-base status will directly influence management.

ABG analysis provides:

• PaO₂ for assessment of oxygenation
• PaCO₂ for assessment of alveolar ventilation
• pH for assessment of acid-base balance

ABGs may be particularly useful in severe asthma, COPD exacerbations, drug overdose, respiratory failure, chest trauma, heart failure, pneumonia, neurologic injury, and patients receiving mechanical ventilation.

Results should always be interpreted together with the clinical examination. A rising PaCO₂ in a severely distressed patient may indicate respiratory muscle fatigue and declining alveolar ventilation. Worsening acidemia further increases concern for ventilatory failure.

Acute Asthma in the Emergency Department

Acute asthma is one of the most common respiratory emergencies.

During an exacerbation, bronchial smooth muscle constriction, airway inflammation, mucosal edema, excessive mucus production, and mucus plugging increase airway resistance. Patients may develop wheezing, tachypnea, prolonged expiration, accessory muscle use, anxiety, hypoxemia, and hyperinflation.

Emergency assessment should evaluate:

• Severity of dyspnea
• Ability to speak
• Respiratory rate
• Heart rate
• Work of breathing
• Mental status
• Breath sounds
• Oxygen saturation
• Peak expiratory flow when possible
• Arterial blood gases in severe cases

Note: A patient with moderate asthma may be able to speak only in phrases, while severe disease may limit speech to individual words. Life-threatening asthma may cause confusion, exhaustion, paradoxical breathing, bradycardia, severe hypoxemia, rising PaCO₂, acidosis, or a nearly silent chest.

Peak Expiratory Flow

Peak expiratory flow rate may be used to assess airway obstruction and response to treatment. Measurements can be obtained before and after bronchodilator therapy when the patient can perform an acceptable maneuver.

However, severely dyspneic patients may be unable to complete the test. Repeated attempts can increase fatigue and delay treatment. Bronchodilator therapy should not be postponed simply to obtain a peak-flow measurement.

Bronchodilator Therapy

Short-acting beta-2 agonists are commonly used for acute bronchospasm. Albuterol is one of the most frequently administered medications because it produces rapid relaxation of bronchial smooth muscle.

It may be delivered by nebulizer or by metered-dose inhaler with a holding chamber. Both methods can provide effective bronchodilation when used correctly. During severe exacerbations, albuterol may be given repeatedly or by continuous nebulization.

Ipratropium bromide may be added to short-acting beta-agonist therapy when additional bronchodilation is needed, particularly in more severe exacerbations.

Patients receiving frequent or high-dose beta-agonist therapy require monitoring because adverse effects may include tachycardia, tremor, nervousness, hyperglycemia, and hypokalemia.

Corticosteroid Therapy

Systemic corticosteroids are commonly used during moderate or severe asthma exacerbations. Bronchodilators directly relax airway smooth muscle, while corticosteroids reduce airway inflammation.

Because corticosteroids do not produce immediate bronchodilation, they should not replace rescue bronchodilators during an acute episode. Intravenous or oral corticosteroids may be administered depending on the patient’s severity and ability to tolerate medication.

Controller medications such as cromolyn sodium or long-acting beta-2 agonists are not substitutes for rapid-acting bronchodilators during emergency treatment.

Signs of Worsening Asthma

One of the most important responsibilities during asthma treatment is recognizing respiratory fatigue. A patient may initially hyperventilate and have a low PaCO₂. If the PaCO₂ begins rising toward normal despite persistent severe respiratory distress, the patient may be losing the ability to sustain ventilation.

Additional warning signs include:

• Increasing fatigue
• Reduced air movement
• Altered mental status
• Worsening hypoxemia
• Increasing acidosis
• Decreasing respiratory effort
• Silent chest
• Thoracoabdominal paradox

Note: These findings may indicate impending respiratory failure.

Noninvasive Ventilation in Asthma

Noninvasive positive-pressure ventilation may be considered in selected patients with severe asthma who remain alert, cooperative, and capable of protecting the airway. The goal is to decrease work of breathing and improve ventilation without intubation.

Noninvasive ventilation is not appropriate when the patient is severely obtunded, hemodynamically unstable, unable to protect the airway, or rapidly progressing toward respiratory arrest. Delaying necessary intubation in a deteriorating patient can worsen outcomes.

Mechanical Ventilation in Severe Asthma

Mechanical ventilation may become necessary when respiratory fatigue, severe hypercapnia, altered consciousness, or worsening oxygenation indicates that spontaneous ventilation is no longer adequate. Ventilator management must account for severe expiratory airflow obstruction.

A relatively low respiratory rate and modest tidal volume help reduce air trapping. Tidal volumes are often set around 6 to 8 mL/kg of predicted body weight.

Long expiratory times are important. Inspiratory-to-expiratory ratios such as 1:4 or 1:5 may be used to allow more complete exhalation. Plateau pressure should generally be maintained at or below approximately 30 cm H₂O. Permissive hypercapnia may be tolerated in some patients as long as severe acidemia does not develop.

COPD Exacerbations

Patients with COPD may arrive with increased dyspnea, cough, sputum production, wheezing, hypoxemia, or worsening hypercapnia. Assessment should evaluate respiratory rate, mental status, work of breathing, breath sounds, oxygen saturation, arterial blood gases, and clinical evidence of respiratory muscle fatigue.

COPD exacerbations can cause acute respiratory failure superimposed on chronic hypercapnia. A patient with increasing accessory muscle activity, paradoxical abdominal movement, worsening PaCO₂, and declining pH may be approaching ventilatory failure.

Treatment may include oxygen, bronchodilators, corticosteroids, noninvasive ventilation, secretion management, and mechanical ventilation when necessary.

Obesity-Hypoventilation Syndrome

Obesity-hypoventilation syndrome may also produce acute-on-chronic hypercapnic respiratory failure. Treatment depends largely on severity.

A conscious and hemodynamically stable patient with moderate respiratory acidosis may respond to noninvasive positive-pressure ventilation.

A patient who is obtunded, unstable, or severely acidemic may require endotracheal intubation and invasive mechanical ventilation. The airway, breathing, and circulation priorities remain the same as in other respiratory emergencies.

Chest Trauma

Chest trauma can cause rapid deterioration in both ventilation and oxygenation. Possible complications include pneumothorax, hemothorax, pulmonary contusion, rib fractures, airway injury, vascular injury, aspiration, and acute respiratory distress syndrome.

Initial assessment should evaluate chest movement, breath sounds, oxygenation, work of breathing, airway patency, and hemodynamic status. A patient with significant trauma may receive high-concentration oxygen while injuries are being evaluated.

Pneumothorax

Pneumothorax should be suspected when a patient develops sudden chest pain, shortness of breath, diminished breath sounds, or asymmetrical chest movement. Hyperresonance to percussion may indicate excess air within the thorax. A tension pneumothorax can cause progressively severe cardiopulmonary compromise.

Possible findings include:

• Markedly diminished or absent breath sounds
• Hypoxemia
• Hypotension
• Tracheal deviation away from the affected side
• Mediastinal displacement
• Severe respiratory distress

Note: Tension pneumothorax requires immediate treatment.

Subcutaneous Emphysema

Air leaking from an injured lung may enter surrounding tissues and produce subcutaneous emphysema. Palpation may reveal crepitus, a crackling sensation beneath the skin.

This finding may be associated with pneumothorax, pneumomediastinum, rib fractures, or airway injury. The presence of crepitus should prompt evaluation for an underlying thoracic air leak.

Pulmonary Contusion

Pulmonary contusion involves bruising of lung tissue with accumulation of blood and edema. Gas exchange may deteriorate progressively after injury. A chest radiograph may show pulmonary infiltrates, but radiographic changes can sometimes appear after the initial injury.

Supportive respiratory care may include oxygen, careful fluid management, pain control, ventilatory support, and monitoring for worsening hypoxemia.

Secretion Retention After Trauma

Chest trauma frequently causes pain and limits the patient’s ability to cough or take deep breaths. This may lead to reduced tidal volume, mucus retention, and atelectasis.

Respiratory care may include positioning, mobilization, airway-clearance techniques, and lung-expansion therapy when appropriate.

Care must be taken when an untreated pneumothorax or other unstable chest injury is suspected because certain positive-pressure techniques may worsen the condition.

Spinal Cord Injury

Spinal cord injuries can significantly affect respiratory function, especially when the cervical spinal cord is involved. Assessment should include chest and abdominal movement, respiratory rate, oxygen saturation, end-tidal carbon dioxide, airway patency, and associated head or chest injuries.

A patient who becomes apneic after high cervical trauma requires immediate manual ventilation. Supplemental oxygen may initially be delivered at a high concentration while stabilization continues.

Suctioning should be performed carefully because vagal stimulation may cause profound bradycardia. Intubation techniques should preserve cervical alignment.

Glasgow Coma Scale and Airway Protection

The Glasgow Coma Scale is frequently used to evaluate neurologic status after trauma. Declining consciousness increases the risk of airway obstruction, aspiration, and loss of protective airway reflexes.

A Glasgow Coma Scale score below approximately 8 commonly indicates the need to consider endotracheal intubation and airway protection unless treatment limitations are already established.

Neurologic evaluation should continue after airway stabilization because changes in ventilation can influence cerebral blood flow.

Smoke Inhalation and Carbon Monoxide Exposure

Smoke inhalation may expose the patient to thermal injury, particulates, carbon monoxide, toxic gases, and cyanide. Initial chest imaging may appear normal even when significant airway or pulmonary injury is developing.

Patients may later develop wheezing, crackles, airway edema, bronchospasm, hypoxemia, or respiratory failure.

High-concentration oxygen should be administered immediately when significant carbon monoxide exposure is suspected. CO-oximetry is required to measure carboxyhemoglobin accurately.

Heliox Therapy

Heliox may occasionally be used in severe airflow obstruction. Because helium is less dense than nitrogen, helium-oxygen mixtures can reduce turbulent airflow and decrease airway resistance.

Heliox may therefore reduce the work of breathing in selected patients with severe asthma or upper-airway narrowing.

When heliox is administered through a reservoir system, the reservoir bag should remain inflated. Collapse of the bag indicates that gas flow is insufficient to meet the patient’s inspiratory demand.

Pulmonary Edema and Heart Failure

Acute pulmonary edema may occur when left ventricular failure causes pressure to rise within the pulmonary circulation. Fluid moves into the pulmonary interstitium and alveoli, impairing gas exchange.

Patients may present with severe dyspnea, tachypnea, anxiety, cyanosis, crackles, rhonchi, and frothy pink or white secretions.

Treatment may include supplemental oxygen, medications, diuretics, and continuous positive airway pressure. CPAP can improve oxygenation and reduce the work of breathing in appropriate patients.

Differentiating Cardiac and Pulmonary Causes of Dyspnea

Dyspnea may result from either pulmonary or cardiovascular disease. Patients with both COPD and heart failure can be especially difficult to evaluate. Clinical findings should be considered together with diagnostic information.

Cardiac troponins may support the diagnosis of myocardial injury, while elevated brain natriuretic peptide may support heart failure.

Respiratory findings, chest imaging, oxygenation, ABG results, medical history, and response to therapy should also be integrated into the assessment.

Drug Overdose and Respiratory Depression

Drug overdose may cause severe depression of respiratory drive. Patients may arrive unconscious with slow, shallow breathing, vomiting, aspiration, hypoxemia, and hypercapnia.

Immediate priorities include airway protection and ventilatory support. Manual ventilation with a bag-mask device may be necessary until endotracheal intubation and mechanical ventilation are established.

Airway suctioning may also be required if vomitus or secretions are present. Specific antidotes may be administered when appropriate, but reversal of the toxic substance should not delay essential oxygenation and ventilation.

Cardiac Arrest and Resuscitation

Respiratory therapists play a major role during cardiac arrest. Basic life support begins with recognition of unresponsiveness and absent normal breathing. The emergency response system should be activated, and healthcare providers should quickly assess for a pulse.

If a pulse cannot be identified within approximately 10 seconds, chest compressions should begin.

Respiratory responsibilities may include airway positioning, bag-mask ventilation, oxygen administration, placement of airway adjuncts, assistance with intubation, suctioning, confirmation of endotracheal tube placement, and mechanical ventilation.

Training in CPR, Advanced Cardiovascular Life Support, Pediatric Advanced Life Support, and neonatal resuscitation improves readiness for these emergencies.

Post-Cardiac Arrest Respiratory Care

Respiratory care continues after spontaneous circulation has returned. The patient requires close monitoring of oxygenation, ventilation, cardiovascular status, and neurologic function.

If spontaneous breathing remains inadequate, mechanical ventilation should be provided through a properly positioned artificial airway.

ABGs may be used to guide ventilator adjustments. Excessive ventilation should be avoided because increased intrathoracic pressure and hypocapnia may impair coronary and cerebral blood flow.

Pediatric Emergency Respiratory Care

Children can deteriorate rapidly because of smaller airways and limited respiratory reserve. Assessment should consider respiratory rate, retractions, nasal flaring, air entry, oxygen saturation, mental status, feeding ability, speech, and level of activity.

Continuous reassessment is especially important. A child who initially appears stable may become fatigued after prolonged increased work of breathing.

Pediatric Asthma

Pediatric asthma treatment commonly includes supplemental oxygen, inhaled short-acting beta-2 agonists, corticosteroids, and ipratropium in more severe cases.

Albuterol may be administered by nebulizer or metered-dose inhaler with a valved holding chamber. Repeated treatment may be required every 20 minutes during the initial hour in severe episodes.

Continuous nebulized albuterol may be considered when repeated intermittent therapy is inadequate.

Children should be observed for tachycardia, tremor, worsening respiratory distress, and other adverse effects. Hospitalization may be required when improvement remains inadequate despite aggressive treatment.

Croup

Croup causes upper-airway narrowing and commonly produces inspiratory stridor. Assessment should include respiratory rate, retractions, air entry, oxygen saturation, and mental status.

Increasing retractions, irritability, altered consciousness, or decreased air movement indicate worsening severity. Nebulized racemic epinephrine may be used to reduce airway edema through vasoconstriction. Dexamethasone provides anti-inflammatory treatment.

A child may be considered for discharge when stridor and retractions have resolved and improvement remains stable during an observation period. Severe respiratory distress or exhaustion may require endotracheal intubation.

High-Flow Nasal Cannula in Pediatric Patients

High-flow nasal cannula therapy may be used in selected children with acute respiratory distress. Potential goals include reducing respiratory rate, decreasing retractions, improving gas exchange, increasing functional residual capacity, and reducing work of breathing.

Patients receiving high-flow therapy require close monitoring for improvement or continued deterioration. Failure to improve may require escalation to noninvasive or invasive ventilation.

Disaster Triage

Respiratory therapists may also participate in disaster response. Patients are triaged according to injury severity and urgency of treatment.

Minor injuries may receive delayed evaluation, while patients with immediately life-threatening but treatable airway, breathing, or circulatory compromise receive the highest priority.

During chemical, biological, radiological, or nuclear incidents, decontamination may be necessary before the patient enters the healthcare facility.

Infection Control in Emergency Respiratory Care

Emergency treatment does not eliminate the need for infection-control practices. Respiratory equipment contaminated with blood or body fluids must be handled appropriately.

Standard precautions include hand hygiene, use of gloves when indicated, safe sharps disposal, and proper cleaning or disinfection of reusable equipment.

A pulse oximeter or other device contaminated with blood after trauma care must be disinfected according to institutional procedures for blood-contaminated equipment.

Continuous Reassessment

One of the most important principles in emergency respiratory care is repeated reassessment. Treatment decisions should not be based on a single oxygen saturation, blood gas, breath sound, or vital sign. The patient’s response to therapy must be continuously evaluated.

Signs of improvement may include reduced respiratory rate, decreased accessory muscle use, improved mental status, stronger breath sounds, improved oxygen saturation, improved peak expiratory flow, and less subjective dyspnea.

Signs of deterioration may include increasing fatigue, worsening hypoxemia, rising PaCO₂, declining pH, altered consciousness, weaker air movement, hemodynamic instability, or apnea.

When a patient deteriorates during respiratory therapy, the treatment should be stopped if appropriate, the patient should be stabilized, and additional assistance should be obtained immediately.

Escalation of Respiratory Support

Emergency respiratory support should match the severity of illness. A patient may initially require only supplemental oxygen and medications, but worsening respiratory status may require increasingly aggressive therapy.

Possible escalation includes:

• Supplemental oxygen
• Aerosolized bronchodilator therapy
• High-flow nasal cannula
• CPAP
• Noninvasive positive-pressure ventilation
• Manual ventilation
• Endotracheal intubation
• Invasive mechanical ventilation

Note: The decision to escalate support should be based on the patient’s clinical condition rather than waiting for complete respiratory collapse. Altered consciousness, severe fatigue, worsening blood gases, hemodynamic instability, persistent hypoxemia, or inability to protect the airway may signal the need for invasive ventilation.

Emergency Department Respiratory Care Practice Questions

1. What is the primary purpose of the emergency department?
The emergency department provides rapid evaluation, stabilization, and treatment for patients with acute, severe, or potentially life-threatening illnesses and injuries.

2. What is the respiratory therapist’s main role in the emergency department?
The respiratory therapist helps assess and manage problems involving the airway, breathing, oxygenation, ventilation, and cardiopulmonary function.

3. What should be prioritized during the initial assessment of a critically ill patient?
Immediate threats to the airway, breathing, and circulation should be identified and treated first.

4. What respiratory findings should be assessed during an emergency evaluation?
The respiratory therapist should assess respiratory rate, breathing pattern, work of breathing, breath sounds, oxygenation, mental status, and the patient’s overall appearance.

5. What are common signs of increased work of breathing?
Common signs include tachypnea, accessory muscle use, nasal flaring, intercostal retractions, diaphoresis, and abnormal chest or abdominal movement.

6. Why should treatment not be delayed for diagnostic testing during a true respiratory emergency?
Immediate stabilization takes priority because delaying treatment for testing can allow a life-threatening condition to worsen.

7. What should be done for a comatose patient with suspected smoke inhalation?
After confirming airway patency, high-concentration oxygen should be administered immediately without waiting for diagnostic testing.

8. Why can standard pulse oximetry be misleading in carbon monoxide poisoning?
Standard pulse oximetry cannot reliably distinguish oxyhemoglobin from carboxyhemoglobin, so the displayed oxygen saturation may appear falsely reassuring.

9. What test should be used to evaluate suspected carbon monoxide poisoning?
CO-oximetry should be used to identify and measure carboxyhemoglobin.

10. What information does an arterial blood gas provide in the emergency department?
An arterial blood gas provides information about oxygenation, alveolar ventilation, and acid-base status through measurements such as PaO₂, PaCO₂, and pH.

11. When is arterial blood gas analysis particularly useful in emergency respiratory care?
It is useful when severe abnormalities in oxygenation, ventilation, or acid-base balance may influence immediate treatment decisions.

12. What is a common first-line bronchodilator for an acute asthma exacerbation?
Albuterol, a short-acting beta-2 agonist, is commonly used for rapid bronchodilation during acute asthma.

13. What is the primary purpose of beta-2 agonists during an asthma exacerbation?
Beta-2 agonists relax bronchial smooth muscle and reduce reversible bronchoconstriction.

14. What medication may be added to albuterol during a severe asthma exacerbation?
Ipratropium bromide may be added to provide additional bronchodilation.

15. Why are systemic corticosteroids used during acute asthma treatment?
Systemic corticosteroids help reduce airway inflammation and are commonly used in moderate to severe exacerbations.

16. What does a decreasing amount of wheezing accompanied by weaker breath sounds suggest in severe asthma?
It may indicate worsening airflow obstruction because critically reduced airflow can produce less audible wheezing.

17. What does decreasing wheezing with stronger overall breath sounds usually indicate?
It generally suggests improving airflow and reduced bronchial obstruction.

18. Why should peak expiratory flow testing not delay treatment in a severely dyspneic patient?
A severely dyspneic patient may be unable to perform the maneuver, and repeated attempts can increase fatigue while delaying necessary bronchodilator therapy.

19. What should be done if a patient with acute asthma cannot perform an acceptable peak-flow maneuver?
Treatment should proceed, and the inability to perform the measurement should be documented.

20. What change in PaCO₂ may indicate respiratory muscle fatigue during severe asthma?
A PaCO₂ that rises from a previously low level toward normal or above normal may indicate declining ventilation and respiratory muscle fatigue.

21. What are signs of life-threatening asthma?
Signs may include severe fatigue, altered mental status, a silent chest, worsening hypoxemia, rising PaCO₂, respiratory acidosis, bradycardia, and thoracoabdominal paradox.

22. When may noninvasive positive-pressure ventilation be considered in severe asthma?
It may be considered when the patient is conscious, cooperative, able to protect the airway, and does not have contraindications to noninvasive ventilation.

23. When should noninvasive ventilation not delay endotracheal intubation?
It should not delay intubation when the patient has severe respiratory failure, altered consciousness, inability to protect the airway, hemodynamic instability, or rapid deterioration.

24. What ventilator strategy helps reduce air trapping in mechanically ventilated patients with severe asthma?
A relatively low respiratory rate with prolonged expiratory time helps reduce dynamic hyperinflation and air trapping.

25. What tidal volume is commonly used initially when mechanically ventilating a patient with severe asthma?
A tidal volume of approximately 6–8 mL/kg of predicted body weight may be used while monitoring airway pressures, ventilation, and air trapping.

26. What is the significance of accessory muscle use in an emergency respiratory patient?
Accessory muscle use indicates increased work of breathing and may suggest significant respiratory distress or impending fatigue.

27. What does thoracoabdominal paradox suggest in a severely dyspneic patient?
Thoracoabdominal paradox may indicate respiratory muscle fatigue and worsening ventilatory failure.

28. Why is continuous pulse oximetry useful in unstable emergency department patients?
Continuous pulse oximetry allows rapid detection of changes in oxygen saturation and helps guide oxygen therapy.

29. What should be considered when a patient with COPD develops worsening hypercapnia and acidosis?
The patient may be developing acute ventilatory failure and may require noninvasive or invasive ventilatory support.

30. What findings may suggest that a COPD patient is approaching respiratory muscle failure?
Increasing accessory muscle use, paradoxical abdominal movement, worsening PaCO₂, declining pH, and altered mental status may indicate respiratory muscle failure.

31. When may noninvasive ventilation be appropriate for obesity-hypoventilation syndrome?
It may be appropriate when the patient is conscious, hemodynamically stable, and experiencing acute-on-chronic hypercapnic respiratory failure without severe instability.

32. When is intubation more appropriate than noninvasive ventilation in obesity-hypoventilation syndrome?
Intubation is more appropriate when the patient is obtunded, hemodynamically unstable, severely acidemic, or unable to protect the airway.

33. What is one of the most important respiratory concerns in a patient with major chest trauma?
The respiratory therapist must rapidly identify conditions that impair ventilation or oxygenation, such as pneumothorax, hemothorax, pulmonary contusion, or airway injury.

34. What physical finding may suggest a pneumothorax?
A hyperresonant percussion note with diminished breath sounds on the affected side may suggest a pneumothorax.

35. What is tracheal deviation away from the affected side associated with in chest trauma?
It may occur with a tension pneumothorax and indicates severe pressure buildup within the affected hemithorax.

36. What does crepitus under the skin of the neck or chest indicate?
Crepitus suggests subcutaneous emphysema caused by air escaping into the surrounding tissues.

37. What conditions may be associated with subcutaneous emphysema?
Subcutaneous emphysema may occur with pneumothorax, pneumomediastinum, rib fractures, or tracheobronchial injury.

38. What is a pulmonary contusion?
A pulmonary contusion is bruising of lung tissue that causes blood and edema to accumulate within the lung and interfere with gas exchange.

39. Why may respiratory problems from a pulmonary contusion worsen over time?
Edema and bleeding within the lung tissue can progress after the initial injury, causing delayed deterioration in oxygenation.

40. Why are pain control and secretion clearance important after chest trauma?
Pain may reduce deep breathing and coughing, which increases the risk of mucus retention, atelectasis, and worsening ventilation.

41. Why must positive-pressure techniques be used cautiously in some chest trauma patients?
Positive pressure may worsen an undiagnosed or untreated pneumothorax or other unstable thoracic injury.

42. What should be suspected in a patient with blunt trauma until proven otherwise?
A cervical spine injury should be suspected, especially when the mechanism of injury could involve the head or neck.

43. How should the airway be managed in a trauma patient with suspected cervical spine injury?
Airway management should maintain the head and neck in neutral alignment and avoid unnecessary neck movement or hyperextension.

44. What is the purpose of manual inline stabilization during intubation?
Manual inline stabilization helps limit movement of the cervical spine while the airway is being secured.

45. What does a Glasgow Coma Scale score below 8 generally suggest?
A score below 8 generally suggests severe neurologic impairment and a need to consider securing the airway with endotracheal intubation.

46. Why is frequent neurologic reassessment important after major trauma?
A patient’s level of consciousness can decline rapidly, increasing the risk of airway loss, aspiration, and respiratory failure.

47. Why should vigorous suctioning be avoided in some patients with acute spinal cord injury?
Vigorous suctioning can stimulate the vagus nerve and produce severe bradycardia.

48. What should be done if a patient with a suspected high cervical spinal cord injury becomes apneic?
Immediate manual ventilation should be provided while the airway is secured and definitive ventilatory support is arranged.

49. What is the purpose of log-rolling a patient with suspected spinal injury?
Log-rolling allows repositioning while keeping the head, neck, and torso aligned to reduce spinal movement.

50. Why is end-tidal carbon dioxide monitoring useful in severe spinal cord injury?
End-tidal carbon dioxide monitoring helps assess ventilation and can identify worsening hypoventilation or respiratory failure.

51. What is a major respiratory concern in smoke inhalation injury?
Airway edema, bronchospasm, toxic gas exposure, and delayed respiratory deterioration can compromise oxygenation and ventilation.

52. Why can a chest radiograph initially appear normal after smoke inhalation?
Pulmonary and airway injury may evolve over time, so significant respiratory complications can develop even when early imaging is unremarkable.

53. What is the purpose of giving high-concentration oxygen to a patient with suspected carbon monoxide exposure?
High-concentration oxygen helps accelerate the removal of carbon monoxide from hemoglobin and improves oxygen availability.

54. What is heliox?
Heliox is a mixture of helium and oxygen used in selected patients to reduce turbulent airflow and decrease airway resistance.

55. When may heliox be considered in emergency respiratory care?
Heliox may be considered in severe airflow obstruction, such as severe asthma or certain forms of upper-airway narrowing.

56. What does collapse of the reservoir bag during heliox therapy suggest?
It suggests that the gas flow is insufficient to meet the patient’s inspiratory demand.

57. What should be done if the reservoir bag collapses during heliox administration?
The gas flow should be increased so that the reservoir remains adequately inflated during inspiration.

58. Why can intermittent positive-pressure breathing worsen discomfort in an obstructive lung disease patient?
If exhalation time is too short, positive-pressure breaths may increase air trapping and make the lungs feel excessively full.

59. What is the main respiratory danger of opioid overdose?
Opioids can depress respiratory drive, leading to hypoventilation, hypercapnia, hypoxemia, and possible respiratory arrest.

60. What immediate respiratory support may be needed in severe opioid-induced ventilatory failure?
The patient may require airway support, manual ventilation, oxygen, and possibly endotracheal intubation with mechanical ventilation.

61. Why is suctioning often necessary in an unconscious overdose patient?
Vomiting and retained secretions can obstruct the airway and increase the risk of aspiration.

62. What is the respiratory therapist’s role during cardiac arrest?
The therapist may assist with airway positioning, bag-mask ventilation, oxygen delivery, airway adjuncts, intubation, suctioning, and mechanical ventilation.

63. How long should a healthcare provider spend checking for a pulse during cardiac arrest assessment?
A pulse check should generally take no more than about 10 seconds.

64. What should occur if no pulse is identified within about 10 seconds?
Chest compressions should begin while resuscitation efforts continue.

65. Why should excessive ventilation be avoided during cardiopulmonary resuscitation?
Excessive ventilation can increase intrathoracic pressure and reduce venous return, coronary perfusion, and cerebral blood flow.

66. What respiratory monitoring is important after return of spontaneous circulation?
Oxygenation, ventilation, airway position, arterial blood gases, and the need for ongoing mechanical ventilation should be reassessed.

67. Why may mechanical ventilation be required after successful resuscitation?
The patient may remain apneic or have inadequate spontaneous breathing despite restoration of circulation.

68. What is pulmonary edema associated with left ventricular failure?
It is the accumulation of fluid in the pulmonary interstitium and alveoli caused by increased pulmonary vascular pressure.

69. What breath sounds are commonly associated with acute pulmonary edema?
Crackles are common, and rhonchi may also be present when fluid accumulates in the airways.

70. What type of sputum may occur in severe pulmonary edema?
Patients may produce frothy white or pink secretions.

71. How can CPAP help a patient with acute cardiogenic pulmonary edema?
CPAP can improve oxygenation, recruit alveoli, and reduce the work of breathing.

72. What laboratory marker can support the diagnosis of congestive heart failure in a dyspneic patient?
An elevated brain natriuretic peptide level can support the presence of heart failure.

73. What laboratory tests can help identify myocardial injury in a patient with acute dyspnea?
Cardiac troponins and other cardiac enzymes can help identify myocardial injury.

74. Why must oxygen delivery be assessed beyond pulse oximetry in severe blood loss?
A patient can have a normal or high oxygen saturation but still have poor tissue oxygen delivery if hemoglobin concentration and cardiac output are severely reduced.

75. What three major factors influence tissue oxygen delivery?
Tissue oxygen delivery depends primarily on arterial oxygen content, hemoglobin concentration, and cardiac output.

76. Why are children at greater risk for rapid respiratory deterioration in the emergency department?
Children have smaller airways, less respiratory reserve, and can become fatigued quickly when work of breathing remains elevated.

77. What findings should be assessed in a child with acute respiratory distress?
Assessment should include respiratory rate, retractions, nasal flaring, air entry, oxygen saturation, mental status, ability to speak or feed, and overall activity level.

78. What does inability to perform a usual peak-flow maneuver suggest in a child with asthma?
It may indicate severe airflow obstruction and a need for more intensive treatment.

79. How often may albuterol be given during the first hour of a significant pediatric asthma exacerbation?
Albuterol may be given approximately every 20 minutes during the first hour when clinically indicated.

80. When may continuous nebulized albuterol be considered in a child with severe asthma?
It may be considered when repeated intermittent bronchodilator treatments fail to provide adequate improvement.

81. What factors may support hospital admission after treatment for pediatric asthma?
Poor response to several hours of treatment, need for continuous bronchodilators, recent emergency visits, previous hospitalization or ICU admission, and persistent respiratory distress may support admission.

82. What is the characteristic breath sound associated with croup?
Inspiratory stridor is the characteristic sound associated with upper-airway narrowing from croup.

83. Why can oxygen desaturation be a late finding in a child with upper-airway obstruction?
A child may maintain oxygenation for a period despite increasing airway resistance and work of breathing, so worsening effort can occur before saturation falls.

84. What medication is commonly nebulized to reduce airway edema in moderate to severe croup?
Nebulized racemic epinephrine may be used to reduce upper-airway edema through vasoconstriction.

85. What is the role of dexamethasone in the treatment of croup?
Dexamethasone reduces airway inflammation and helps decrease swelling in the upper airway.

86. Why should a child be observed after receiving racemic epinephrine for croup?
The medication’s effect decreases over time, so observation helps determine whether stridor or respiratory distress returns.

87. When may intubation become necessary in a child with severe croup?
Intubation may be necessary when severe airway obstruction causes exhaustion, worsening respiratory distress, declining air movement, or impending respiratory failure.

88. Why may a smaller-than-usual endotracheal tube be required in severe croup?
Subglottic swelling narrows the airway, so a smaller tube may be needed to pass through the edematous region without causing additional trauma.

89. What is the goal of high-flow nasal cannula therapy in pediatric respiratory distress?
The goal is to reduce work of breathing, improve gas exchange, support functional residual capacity, and decrease respiratory distress.

90. What should be done if a child continues to deteriorate despite high-flow nasal cannula therapy?
Respiratory support should be escalated, which may include noninvasive ventilation or endotracheal intubation with mechanical ventilation.

91. Why is close monitoring necessary during aggressive beta-2 agonist therapy in children?
Beta-2 agonists can cause tachycardia, tremor, nervousness, and other systemic effects that may become significant during high-dose therapy.

92. Why is a metered-dose inhaler with a valved holding chamber useful in the emergency department?
When used correctly, it can deliver short-acting bronchodilators effectively and may provide results comparable to nebulizer therapy.

93. Why is cromolyn sodium not appropriate as a rescue medication during an acute asthma attack?
Cromolyn is a preventive medication that does not produce rapid bronchodilation, so it cannot quickly reverse acute bronchospasm.

94. Why are long-acting beta-2 agonists not used as substitutes for rescue bronchodilators during acute asthma?
They are intended primarily for maintenance therapy and are not appropriate replacements for rapid-acting short-acting beta-2 agonists during acute bronchospasm.

95. Why can a nonselective beta blocker worsen respiratory symptoms in a patient with asthma?
Nonselective beta blockers can block beta-2 receptors in the airways and interfere with bronchodilation, potentially worsening bronchoconstriction.

96. What is Kussmaul respiration?
Kussmaul respiration is a deep, rapid breathing pattern that occurs as compensation for metabolic acidosis, such as in diabetic ketoacidosis.

97. Why does metabolic acidosis cause an increase in ventilation?
Increased hydrogen ion concentration stimulates chemoreceptors, which increase ventilation to lower PaCO₂ and partially compensate for the acidosis.

98. How are patients prioritized during disaster triage?
Patients are prioritized according to injury severity, urgency, and the likelihood that immediate treatment of airway, breathing, or circulation problems can improve survival.

99. Why may decontamination be required before a patient enters the emergency department during certain disasters?
Decontamination helps prevent hazardous chemical, biological, radiological, or other contaminants from spreading to healthcare personnel, patients, and the facility.

100. Why is continuous reassessment essential in emergency department respiratory care?
A patient’s cardiopulmonary condition can change rapidly, so repeated assessment helps determine whether treatment is effective, whether deterioration is occurring, and whether respiratory support must be escalated.

Final Thoughts

Respiratory care in the emergency department requires rapid assessment, strong clinical judgment, technical skill, and continuous reassessment.

Respiratory therapists help manage a wide range of emergencies, including asthma, COPD exacerbations, respiratory failure, chest trauma, spinal cord injury, smoke inhalation, pulmonary edema, drug overdose, pediatric airway disease, and cardiac arrest.

The primary goals are to maintain a patent airway, support adequate oxygenation and ventilation, recognize deterioration early, and escalate therapy when necessary. Effective emergency care depends on treating immediate threats first while integrating physical examination findings, laboratory data, imaging, and the patient’s response to treatment.