"I can't breathe!" Respiratory Problems in the ED: Part II by Tom Trimble, RN CEN
This is a review, in a case-based problem solving way, of breathing problems which you may confront in the Emergency Department . 
What this article will do: Provide an opportunity to challenge oneself by analyzing cases (both real and realistically synthesized) of respiratory problems 
that appear in EDs.
The aim is to: Analyze clinical situations with critical thinking, applying Emergency Nursing knowledge and skills, 
to determine the most important impacts that Emergency Nurses can provide.
Utilization & Target Audience: These cases, while intended originally as a presentation to an Emergency Department Training Program for new graduates 
and nurses new to the emergency setting, can be used as a self-review, didactic presentation, interactive discussion between mentor and learner, or as general 
study material to prepare for CEN exam. The focus should be to analyze the problem, find the immediate essential thing to understand or do, and understand why.
What this article is not: It is not a comprehensive treatise on each such case, nor does it describe all pathophysiology, examine or prescribe diagnostic 
& therapeutic pathways, and certainly may be at variance with the reader's local practice. 
Our DISCLAIMER completely applies to each and every part of this article.

Case Twenty-Four: "It must have been something I ate" 
     A hospital worker comes in, having eaten of a coconut cream pie from a bake sale, complaining of itchiness, wheezing, and cough. 
Initially, he seems to improve after a bronchodilator nebulizer treatment, then rapidly decompensates over three minutes with increasing 
labor of respirations, wheezing, diaphoresis, agitation and confusion with combativeness to the oxygen mask. There is great effort to 
the excursion of the chest with skin visibly retracted between the ribs and below the costal margins. The outline of the trachea upon the 
neck appears to sink with inspiratory effort. 
     What is going on? 
1. Acute severe respiratory distress, in extremis, probably from anaphylaxis due to food allergy. 
     Two things must be done immediately. What are they?
1. Epinephrine (Adrenalin®) must be given.
2. The patient must be intubated. 
1. Epinephrine counters bronchospasm & wheezing, increases blood pressure and cardiac output, and diminishes tissue swelling of 
    angioneurotic edema.
2. Intubation is necessary because of the patient's rapid deterioration, altered mental status, and intense bronchospasm. 
     What is the single most important drug to use in this crisis? What other drugs may be called for? 
1. Epinephrine (Adrenaline®). No other drug does so much or so quickly in such a crisis.
2. Diphenhydramine (Benadryl®) may compete for and block histamine receptors. An H2 blocker e.g., Famotidine (Pepcid®), Cimetidine 
    (Tagamet®), Ranitidine (Zantac®) might be used to block the 2nd histamine pathway.
3. Methylprednisolone (Solu-Medrol®) is a steroid to suppress the inflammatory response; however, this effect will take hours.)
4. Albuterol (Proventil® or Ventolin®) as a bronchodilator.
5. Racemic Epinephrine (Vaponefrin®) or even nebulized "regular" epinephrine may shrink swollen airway tissues if there is glottal edema 
    or angioedema.
6. Ketamine (Ketalar®) may be used as an induction agent as it stimulates additional catecholamine release to counter the shock and to 
    cause additional bronchodilatation.
7. HeliOx is a mixture of oxygen and helium to replace the denser nitrogen in air which allows easier flow into tighter spaces with less work. 
     It can make the most of a small airway in oxygenating and carrying nebulized medications.

     In what manner and dose is Epinephrine given? 
1. Epinephrine is given at 0.01 mg/kg; typically 300 mcgs. - 500 mcgs. for an adult (by severity). 
    From a 1:1000 aqueous solution, this is 0.3 - 0.5 ml injected sub-cutaneously in milder situations, intramuscularly if there is concern as to 
    poor uptake due to peripheral vasoconstriction, or (if the patient is in shock and no veins are available) intra-glossal where rapid absorption 
    can occur from the tongue. 
If vascular access is present, Epinephrine can be given intravenously in the 1:10,000 solution (1mg/10ml) slowly. 
An Epinephrine infusion can be prepared by adding 1mg (1ml of 1/1000 solution) to 250 ml of iv fluid and titrating to effect with an 
infusion pump. Our institution's safety precaution is that, except during cardiac arrest, an Attending Physician must be present when 
intravenous Epinephrine is given. 
If an endotracheal tube has been placed and no vascular access is present, Epinephrine may be given via endotracheal tube at 
2-2 1/2 X dose in 5-10 ml. of Normal Saline.
If there is a great deal of airway swelling or refractory bronchospasm, Epinephrine (or Racemic Epinephine = Vaponefrin®) may be 
nebulized in-line with the respiratory circuit. 
     What supplementary measures should be taken? 
1. H1 Anti-histamine. Diphenhydramine (Benadryl®) 50-100 mg IV (if possible)
2. Steroid. Methyl-prednisolone (Solu-Medrol®) 125mg IV.
3. H2 Anti-histamine. Either Cimetidine (Tagamet®), Ranitidine (Zantac®), Famotidine (Pepcid®) to help block the second histamine pathway.
4. Epinephrine infusion, if not already done, for its pressor and bronchodilatory effects. 
     The person bag-ventilating the patient states "the bag is rock-hard!" 
     [increasingly difficult to ventilate with very poor compliance (stiff, tight lungs needing high airway pressure) 
    and very poor tidal volumes: a "rock-hard bag" ] 
     What pathophysiologic mechanisms are or may be at work? What is going on? 
1. Intense bronchoconstriction.
2. Increased airway resistance.
3. Mucosal edema narrowing the lumen of airways
4. Mucosal secretions into the airway lumena
5. Laryngospasm
6. Transudation of fluid into alveoli and lung parenchyma from capillary permeability leading to water-logged lungs.
7. Negative Pressure Pulmonary Edema due to the high negative intrathoracic pressures generated by the struggle to breathe 
    against the increased work of breathing. 
     How can bag-mask ventilation be improved? 
1. Two-person BVM with one person focusing totally on mask fit, jaw thrust, use of oral and nasal airways; a second person doing 
     the squeezing of the bag.
2. In-line administration of bronchodilators.
3. Continued administration of epinephrine by most effective route available.
4. Rapid Sequence Intubation with Ketamine (enhances bronchodilation by another pathway).
5. Neuromuscular blockade paralysis.
6. Heliox to improve gas flow through tight airways.

     Due to the difficult in ventilation, concern is raised about the accurate placement of the endotracheal tube. 
What methods of verification might be tried? What inaccuracies may occur? 
1. Direct Laryngoscopy to view tube passing between vocal cords. May be difficult; each DL increases airway trauma and swelling.
2. Capnography (with waveform) to determine expired air CO2. In low-flow shock states or cardiac arrests, insufficient CO2 may be 
    expired to make determination.
3. Auscultation of breath sounds. May be unreliable with intense bronchospasm. Not definitive.
4. Esophageal Detector Device (syringe or bulb). Usually reliable, but may be problematic with airway edema and bronchospasm or vomit 
    limiting the amount of air-filled lumen to permit airflow in the syringe or bulb.
5. Chest X-ray. Too slow, not definitive if only taken in the anteroposterior view without a lateral film to see in a ventral-dorsal plane. 
     Interferes with resuscitation effort.
6. Fiberoptic Laryngoscopy per endotracheal tube to view tracheal rings or carina. Definitive. Some setup; qualified user. 
    Brief interruption of ventilation.
7. Lighted Stylet such as Laerdal's TrachLight per endotracheal tube to produce a central and even bright glow transilluminating the neck 
    at the sternal notch. 
    Reliable with experienced user. Neck swelling may limit effect. Room may need brief darkening or drape over head, neck, and airway 
    manager. Brief interruption of ventilation.
8. Gum Elastic Bougie (Eschmann Endotracheal Tube Introducer) per endotracheal tube. An experienced user may feel the coude' tip bump 
    along tracheal rings or crunch to a stop in a bronchus. Brief interruption of ventilation.
9. Frova Intubating Introducer is a hollow bougie on a stiffener that can be placed in a narrow passage to introduce a tube, but whose hollow 
    channel permits oxygen jet ventilation or capnographic sampling. (Low flow states, shock, CPR, may not generate much CO2.)
Diagnosis: Anaphylaxis & Negative Pressure Pulmonary Edema

Case Twenty-Five: "Choking" 
     You respond to an overhead page for "a nurse to check a choking patient!" 
As you scan the arrival area, you ask "Who's the patient?" because nothing appears amiss. 
A woman points to a teenager and says "My son; --he's choking." 
To your eye, he is standing, smiling, appears to have normal color, and is non-distressed. 
"How do you feel?" "OK. I was eating a gumball. It's stuck in here," he says pointing to his neck. 
His voice sounds normal without faltering. 
     Does he need a Heimlich Maneuver? 
1. No. Breathing and speaking are OK. The airway is OK. There is no imminent collapse from anoxia. 
     Your next question is: 
1. "What have you tried, so far?" 
     Your rationale is: 
1. Open-ended questions lead to a natural and detailed response.
2. You want to know any first aid attempts; swallowing efforts, finger probes that might have scratched the throat, whether water 
     can be swallowed, whether he can handle secretions. 
     Your triage category is: 
1. Category One (Emergent - Life Threatening) if can't handle secretions, breathing or voice problems.
2. Category Two (Urgent - Requires prompt attention by MD) if handles secretions well. Take to care area ASAP. 
     Where's the obstruction?
1. Esophageal. The aero portion of the aerodigestive tract is OK as shown by breathing and speaking. 
    The globus sensation, the history, and inability to swallow water show esophageal obstruction. 

Case Twenty-Six: "Persistent Cough" 
     A patient is brought to the ED due to "weakness" which follows upon four weeks of persistent cough, fatigue, 12 pound 
     weight loss, night sweats. 
     Your first acts are to: 
1. Place a mask upon the patient.
2. Notify the Charge Nurse that an isolation room is needed. 
     What do the following have in common? 
· A 27 year old state prisoner in custody who appears to have a number of gang tattoos.
· A 68 year old woman brought from a village in China today by her family living in America so that she could obtain medical care.
· A 35 year old gay man who is HIV seropositive and does not practice safer sex or have a current primary care provider.
· A 41 year old homeless woman with poor skin, scarring from past abscesses, and history of IV drug abuse. 
     All are members of groups at risk for Tuberculosis. 
     Important facts to elicit during assessment are: 
1. When was the patient last tested for Tuberculosis (and details of findings, treatment, followup)?
2. When (and where) was last chest x-ray done?
3. Has the patient received anti-tubercular treatment? (details, #of drugs used, duration).
4. Has the patient received BCG vaccination (Bacille Calmette-Guerin) used for immunization in foreign countries? 
     After isolation, and notification of the providers, the next tasks are: 
1. Chest X-Ray.
2. Sputum samples should be checked for "AFB - Acid-Fast bacilli" i.e., TB.
3. Obtain authorization for and medical records from previous providers and hospitals.
4. Blood culture & sensitivity testing, including AFB.
5. Initiate a sign-in list for all persons entering the room.
6. Remember to advise X-ray or other departments to which the patient might go, and the receiving ward, as to precautions imposed.
Case Twenty-Seven: "Strangely Slow Heartrate" 
     Paramedics respond to a convalescent hospital to take an elderly woman with a bradycardia to the hospital. 
     Departure is delayed while nurses search for missing dentures. The demented patient does not speak. 
     As the search continues, the lead paramedic notices an odd horizontal bulge to the soft tissues of the neck. 
     The missing denture is found having slipped downwards in the throat and is impacted transversely. 
     What is the cause of the bradycardia? 
1. Pressure of the denture probably stimulated the Carotid Sinus Body increasing vagal tone and inducing bradycardia. 
     What is the important lesson of this vignette? 
1. Patients who cannot speak for themselves (whether demented, mute, unconscious, or foreign speaking) cannot explain the problem 
    and are dependant upon your skills and observation.
2. The corollary is that such patients cannot signal for help and will require more frequent safety checks and assessment.
3. A (for Airway) comes before Breathing and Circulation. Although the breathing was apparently unimpaired, sometimes one must do 
     backward reasoning to solve the problem especially with a patient whose mental status is impaired. 
     Why did this occur? 
1. Dentures, especially without adhesives, may slip. Older patients may have ill-fitting dentures due to weight loss and gum shrinkage. 
    With Organic Brain Syndrome, or Tardive Dyskinesia, there may be frequent tongue thrusting or rolling to dislodge them or poor mastication. 
     What tip do we derive from this for Emergency Airway Management? 
1. If dentures are secure, important support for oral architecture is provided which helps with mask ventilation.
2. Loose dentures may need to be removed during laryngoscopy and intubation to improve view and prevent damage.
3. Loose natural teeth must be protected from injury or aspiration. 
    Missing natural teeth or denture pieces must be sought out and accounted for.
Case Twenty-Eight: "Turning Blue!" 
     A young woman and her girlfriend come in because of concern that the patient's hands are blue. 
     The hands are cyanotic in appearance. The young woman seems anxious and concerned about this symptom. 
      It has been a gray, cold, damp day with intermittent rain. The patient had been in "Usual State of Health." 
     What findings will you want to elicit? 
1. Breathing, although somewhat faster consistent with anxiety, is unlabored, and without sense of dyspnea.
2. Pulse oximetry indicates SPO2 of 100%
3. Skin temperature is equal between hands, and seems reasonably warm and well-perfused with good nail bed capillary refill. 
     Pulses are strong. 
     What is going on here? 
1. There seems to be no cardiopulmonary abnormality.
2. No history supports a differential diagnosis of methemoglobinemia or cyanide poisoning.
3. The patient is wearing brand new overdyed indigo blue jeans.
     Given the circumstances, is there a clinical test? 
1. The affected areas of skin are wiped with an alcohol wipe, blue color is removed from the skin and transferred to the alcohol wipe.
2. Upon removal of the blue jeans, it is noted that the anterior thighs, and other areas less so according to contact and pressure, are 
    also blue, and respond to alcohol removal also. 
     What happened? 
Diagnosis: Spurious Cyanosis related to Dye-Transfer to skin. 
Case Twenty-Nine: "Sick and fevered" 
     You have just come into work, and you notice that a nurse is very busy in the isolation room with a rather ill patient (to whom you gave 
      care the preceding night). The patient is homeless, has fever (40.5° C), tachypnea 32-36, cough & night sweats, and Left 
      Hemi-Thorax "White-Out" on CXR and Chest CT. You go in to help. 
     The nurse has just given acetaminophen, lorazepam for alcohol withdrawal, and is starting antibiotics. You notice that the patient seems 
      hot, hyperdynamic in vital signs, restless, and breathing hard. The nurse has just finished oral suctioning with a Yankauer tip. 
     The patient starts snoring loudly with each inspiration. 
     Your action is to:
1. Replace the oxygen mask and perform a chin-lift. The effort of breathing decreases somewhat as does the volume of the snoring.
2. You now reposition bedding as a shoulder roll to help maintain head tilt and neck extension. Nothing changes.
3. You do a jaw lift, maintaining head tilt, chin lift, and neck extension, by hooking your fingers under the mandible and behind the 
     ramus and prognath the jaw, anteriorly displacing the lower jaw so that its teeth in front of the upper teeth. 
     Effort and sound decrease somewhat. 
     You notice that the patient is transmitting a vibratory sensation to your hand, the skin of the neck seems to "flap" a bit, and inspiratory 
     effort of the chest produces a downward "tug" of the trachea. 
     What's going on? 
1. A partial obstruction of the upper airway still exists despite your vigorous manual efforts. The high inspiratory negative pressures generated 
    are drawing the soft tissues of the neck inwards creating fremitus and contributing to the obstruction. 
     Your next actions? 
1. As you judge his level of consciousness to probably not tolerate an oral airway, you inspect his nares to judge size and clearer passage.
2. You call for a nasopharyngeal airway (30 french Robertazzi) and Lidocaine jelly (2%, 5 ml) to be brought as you maintain the airway 
     manually [[email protected]=100% on 100% non-rebreather oxygen mask].
3. The airway is gently inserted via the larger nasal passage with immediate easing of breathing effort and stertor. 
     What happened?
1. As the patient's fever peaked, his metabolic requirements for oxygen peaked.
2. His ability to oxygenate was compromised by his total left lung consolidation.
3. This forced a need for increased respiratory rate and depth, causing increased work of breathing and higher negative pressures 
     (more work by the bellows).
4. This influence upon the soft tissues of his airway was compounded by the sedation of the Lorazepam increasing the flaccidity of those 
     tissues leading to airway obstruction not responsive to manual measures.
5. The airway obstruction was relieved by the nasopharyngeal airway separating and displacing the soft tissues so that a clear passage 
     was obtained.
6. As the patient had ruled in for Tuberculosis, you are glad to have practiced good isolation, worn your approved mask or positive air pressure 
     hood, worn gloves and performed good hand washing. 
Case Thirty: "New Asthma" 
     An eleven year old girl is brought in by parents for worsened difficulty breathing. Overall, she is in good condition, with some wheezy 
     and coarse breath sounds throughout the respiratory cycle. She is two days post discharge from another hospital of a three day stay for 
     "New Onset Asthma." A bronchodilator treatment makes only a mild improvement. 
     History is gathered in this puzzling case. No prior history of asthma, rhinitis or sinus problems, hay fever, eczema or other rashes. 
     No family history of same. No exposure to smoke, fumes, or toxic irritants. No URI or recent bronchitis or viral illness. Essentially 
     normal voice, no sore throat or redness seen, but some neck discomfort, occasional non-productive cough. 
     What's wrong here? 
     Normal findings, absence of allergic/atopic history in patient or family; older age for new onset asthma. 
     No acute or lingering ill process. Adventitious sounds throughout the respiratory cycle. Throat discomfort. 
     What are you looking for? What is found? 
1. Epiglottitis (less likely in age group or HIB vaccination)
2. Croup (viral or bacterial Laryngotrachealbronchitis)
3. Soft-tissue infection or abscess (no fever, odynophagia, or palpable swelling)
4. Aspirated foreign body (less likely due to age)
5. Found is an aspirated pumpkin seed that is impacted in the trachea inciting airway inflammation and reactivity. 
    (It was not found on the chest X-ray at the other hospital because the film did not come up high enough to see the seed in the neck. 
    It was not suspected due to age and lack of history of aspiration. The diagnosis was further erroneous for failing to consider an inhaled 
    foreign body as the cause of adventitious sounds such as wheeze and stridor which were present throughout inspiratory as well as 
    expiratory phases. Good recovery ensued. "All that wheezes is not asthma.") 
     What will the plan be? 
1. Admit for rigid bronchoscopy and foreign body extraction, antibiotics, and pulmonary care.
Case Thirty-One: "C/P & SOB" 
     A young woman presents at triage complaining of a sudden but persistent sharp pain in the left chest below the shoulder and a 
     sense of shortness of breath. She appears well, in Usual State of Health, with normal vital signs. She is concerned because of family 
     history of "heart trouble". She is slim, tall, does not smoke, drink, or use drugs, has no history of gastric reflux, or undue musculoskeletal 
     exertion. No activity was associated with onset. Lung sounds do not seem remarkable. 
     Physical examination leads to CXR. CXR shows a simple Pneumothorax. 
     Why is this so? 
1. Simple Spontaneous Pneumothorax is a known entity, often in young people with tall, slim "asthenic" build.
2. The tall slim build with family history of heart problems suggests the possibility of Marfan's Disease, a familial connective 
     tissue disorder, especially if limbs are disproportionately long. This was not a factor in this case.
3. Cystic Fibrosis, COPD, and other parenchymal or interstitial lung disease can be a factor.
4. There is some association of pneumothorax with strong negative inspiratory pressures in drug use (sucking on a bong).
5. Vital signs may not be deranged in the young and healthy or early in presentation.
6. There is a natural tendency to disbelieve complaints of chest pain if common risk factors (male, middle-aged, hypertensive, 
     hyperlipidemic) are not present. There is also a tendency to consider common differential diagnoses in atypical chest pain. 
     Family history or congenital disease may be present but difficult to evaluate, and was not a factor in this case. 
     What is the probable management? 
1. With a very small pneumothorax that does not increase over time of observation, it is possible that a reliable patient may be discharged.
2. In uncertain cases, the patient may remain for observation.
3. Moderate pneumothorax is treated with tube thoracostomy, possibly with a smaller "pigtail catheter" (Fuhrman pericardial catheter) to 
    Pleur-Evac® water-seal drainage and low continuous wall suction. Some patients can be mobilized with a Heimlich Valve on a drainage set.
4. Admission would be to the Cardiothoracic Surgery service.
Case Thirty-Two: "LOL with SOB"
     An 87-year-old woman with dementia is brought in by family for difficulty breathing. 
     While in the ED, she acutely decompensates and develops frank pulmonary edema with SPO2 of 70% on Non-Rebreather Face Mask 
     oxygen. There is gurgling in the pharynx, and she has been suctioned with a 14 French catheter. There is now blood in the airway, also. 
     Despite her numerous ailments and debility, the family now wish "everything to be done." 
     What is the next thing to be done? 
1. The patient needs to be oxygenated to a higher level. 
     How do you achieve this? 
1. Spontaneous breathing with O2 NRB mask "isn't doing it."
2. Choose either a Jackson-Rees Anesthesia Bag or an O2 BVM (according to your skill level) to give a true FIO2 of 1.0 (100%) with a 
    close-fitting mask.
3. Since the patient is fatigued, obtunded, and hypoxic, you affix the mask closely with a "Triple-Airway Maneuver" for a good airway.
4. If the SPO2 doesn't rise sufficiently spontaneously, you will need to give gentle positive-pressure ventilation.
5. Consider judicious suctioning with a Yankauer tonsil-tip suction to clear the pharynx. Do so gently and under direct vision if possible to 
    avoid further trauma. 
     Why positive-pressure ventilation? 
1. The patient is fatigued from the additional Work-Of-Breathing.
2. The positive-pressure will help drive back the fluid and open more alveoli.
3. The positive-pressure will help oxygen to diffuse across the alveolar membranes and into the blood stream.
4. The positive-pressure will reverse normal intrathoracic pressure dynamics and decrease venous return to the heart and decrease 
     preload; thus helping the heart to improve forward flow. Caution will be necessary to avoid dropping the blood pressure too much.
5. The positive-pressure will help improve the laryngoscopic view by minimizing accumulation of secretions. 
6. You will use gentle positive-pressure ventilation, with an open airway through both inspiratory and expiratory phases of ventilation and 
     adequate exhalation time to minimize gastric insufflation and vomiting. If help is available, the helper can apply Sellick's Maneuver of 
     Cricoid Pressure to minimize passive regurgitation from the stomach being aspirated into the lungs. If the bed can be tilted (and the 
     blood pressure tolerates it), some Reverse Trendelenberg's Position can help.
     The SPO2 rises from 70% to 86%. What do you do next? 
1. Ensure Optimal Mask Ventilation. Assess mask fit, presence of leak, adequacy of airway, ease & feel (compliance) of ventilation.
    Decide if a second person is needed to squeeze the bag while you do two-hand mask fit with triple-airway maneuver 
    (Head Tilt, Open Mouth, Jaw Thrust) or a third person to help with Jaw Lift. 
     SPO2 still does not rise from 86%. What do you do next? 
1. The physician must intubate the patient. It's better than it was and as good as it's going to get! 
     Post-Intubation, the patient improves considerably, but still needs suctioning. What suction device do you choose? 
1. An in-line Closed-System Endotracheal Suction Catheter system, such as the Ballard, is the best choice, as the circuit will not need 
     to be opened nor ventilation interrupted and secretions will not contaminate the room. 
     Remember to "dial down" the maximum negative pressure on the suction system to -100mm H2O pressure to avoid suction trauma. 
Diagnosis: Acute Decompensation of Pulmonary Edema & Airway Bleeding; Difficult Mask Ventilation
Case Thirty-Three: "Frequent Flyer Family" 
     It is a cold wet winter night and you have an entire family of four who are complaining of "'flu" symptoms". 
     It is their third ED visit this week. Everyone has been sick. They come now because the baby and the 
     pre-schooler have been vomiting. All are tired, pale, and nauseous; the adults complain of bad headache. 
     The baby is lethargic and the pre-schooler was OK in the afternoon coming home from day care, but is now not playful or active. 
     The working adult has been fighting it off; -getting through the day all right, but getting sick at night around the family. 
     Everyone seems a little better while waiting 1 ½ hours in the ED waiting room. 
     There has been no fever and no body aches, but the day care child seems to have a runny nose. 
     What's wrong with this picture? 
1. Without fever, myalgias, or gastroenteritis, influenza seems unlikely.
2. Three visits in one week is worrisome.
3. Lethargy in children is always worrisome.
4. There is commonality of symptoms with disparity in severity. The youngest and smallest are the most ill.
5. There is either daytime improvement or nighttime worsening of symptoms, especially in those who are out of the house.
6. There has been interval improvement while waiting (outside of the home environment). 
     What questions must be asked? 
1. What is the family's living situation and what type of heating system is used?
2. Has there been any sort of indoor combustion? 
    (Gas heater, Charcoal hibachi, fireplace, fueled "space heater"; living in an automobile and using the heater for warmth) 
     What is the most likely diagnosis (previously unsuspected)? 
1. Carbon Monoxide intoxication of the group, perhaps from a faulty gas heater. 
     What is the test? 
1. Carboxyhemoglobin level from arterial or venous blood (in a blood gas syringe) sent to the Blood Gas Laboratory 
     specifying co-oximetry to be done (checking for hemoglobinopathies). 
2. Pulse oximeters are now available that can also check for hemoglobinopathies. [Modified 10/30/2012  to reflect change in equipment 
        and practice. Be familiar with your department's equipment and capabilities. An arterial or venous blood gas specimen for co-oximetry is desirable to document findings. TT]
     What is the treatment and clinical trial? 
1. Oxygen given by 100% Non-Rebreather Mask.
2. If all improve on oxygen, then CO poisoning is the most likely diagnosis. 
Diagnosis: Insidious Carbon Monoxide Intoxication during Winter Season
Case Thirty-Four: "Hidden Zinger" 
     A debilitated old woman is brought in by her family due to Shortness of Breath, Weakness, and Fatigue. 
     Her ABG (arterial blood gas) is revealing: pH 7.5 / PCO2 43 / PAO2 40 / HCO3 30 / BE +6 / Sat 77% at FIO2=0.21. 
     What does this ABG tell about the respiratory status? 
1. She is alkalotic (­pH =7.5)
2. She has a normal CO2 =43 (but it's really easy to get rid of CO2)
3. She is severely hypoxic (PAO2 =40).
4. Her status has been going on long enough to cause some metabolic compensation of her respiratory with bicarbonate of 30 
     and base excess of 6. 
     A repeat ABG on 3.5 lpm nasal cannula is 7.48 / 40 / 56 / 31 / +7 / 91% shows modest but insufficient improvement on oxygen, 
     What further interpretation must you make when you find out the Hgb. = 7.8 gms. and Hct.=22%? 
1. The ABG seriously underestimates the respiratory condition in respect of the diminished oxygen carrying capacity due to anemia.
2. The hematocrit is sufficiently low (<25%) that the heart is at risk of ischemia or infarction. 
     Why is this so? 
1. The ABG assumes a normal hemoglobin unless co-oximetry is ordered to calculate the Hgb. 
     The test does not actually calculate oxygen attached to heme in the red blood cell (difficult to do); 
     the sample is calculated from the plasma portion and extrapolated to blood. 
     {At our institution, co-oximetry is only done by the Blood Gas Laboratory; not the "regular" laboratory. 
     Stat chemistry: Sodium, Potassium, Ionized Calcium, and Glucose are only available on ABGs done by the Clinical Laboratory.} 
      Know where in your institution to obtain the appropriate  rapid or "point of care testing" to answer these clinical questions as they arise.
     Will this patient demonstrate cyanosis as a symptom of hypoxia? 
1. No. At least 5 grams of unsaturated hemoglobin must be circulating to show cyanosis. 
    Her erythrocytes are saturated; there are simply not enough of them to provide sufficient oxygen carrying capacity to meet the 
    demands imposed by the pneumonia. 
     What must be done? 
1. Oxygen must be increased (changed to "100% oxygen non-rebreather mask") to increase the amount of oxygen dissolved in plasma.
2. Oxygen carrying capacity must be increased by transfusion of red blood cell mass.

Case Thirty-Five: "Position is everything in life"

    A 180 pound febrile patient presents in wild delirium, and does not understand or follow directions. He is known to have HIV and Hepatitis B. It is necessary to obtain adequate access for what will obviously be a critical care admission, and a lumbar puncture for diagnosis. In an attempt at chemical tranquilization, two 2.5 mgm doses of intramuscular Droperidol are given at cautious intervals; however, as procedures are beginning the patient becomes apneic.

What do you do? Gentle mask ventilation with a BVM is effectively carried out for this patient, even in lateral position for lumbar puncture during the one half hour it takes for him to resume spontaneously breathing.

What has happened? The patient has idiosyncratically had an exquisite response to the sedation due to the meningoencephalitis demonstrated by his CSF and subsequent clinical course.

Comment: Patients are customarily ventilated/intubated in supine position. Some patients may need to be bagged in decubitus position, or even prone, due to secretions, soft-tissue airway obstruction, tumor mass, abscess, or procedural requirements. The Emergency Nurse should be skilled in doing so.

Case Thirty-Six: "Altered Mental Status; now Short of Breath"

    A patient from a Residential Care Facility is brought in because of increased anxiety with agitation thought due to social stressors of the day. Because of repeated rocking and trying to leave bed despite continuous hallway observation and bedside sitter, a Vest type safety restraint is placed. Observation is continuous. Later, he is noted to be slumped and “having trouble breathing.” There is no cyanosis, but a rapid breathing rate with increased work of breathing. The collar is slack without pressure or ligature mark on the neck; the waist belts are also loose. No seizure activity has been witnessed. In the code room, there are no EKG changes, SPO2 is low, the breathing sounds like gurgles. Serum Sodium is 115 mEq/L. Breathing responds to continuous positive airway pressure by mask with the A-Bag, and the patient is intubated.

What has happened? The patient is severely hyponatremic from polydipsia due to his psychiatric medications. The resultant altered mental status and lowered seizure threshold has led to soft tissue and postural airway obstruction (forward flexion of the head and neck). The work of overcoming inspiratory resistance has induced a post-obstructive negative pressure pulmonary edema. (The strong negative pressures generated by working against the obstruction by the thoracic bellows causes fluid to migrate into the alveoli.)

Outcome: Head CT is unchanged, no cardiac damage has occurred by enzymes; respiratory condition stabilizes with support, and hyponatremia is carefully corrected with hypertonic saline infusion.

Case Thirty-Seven:  "Work of Breathing"

    You are assuming care of an admitted patient with Asthma, COPD Exacerbation and  possible pneumonia being held in the Emergency Department >24 hours; his second night. He has been receiving Bi-PAP™ bi-level positive pressure to ease his work of breathing, but it has just been stopped as he “is not tolerating it” and has vomited/regurgitated twice. You see labored breathing with see-saw excursions of the thorax and diaphragm, he’s awake but looks exhausted and has been sleep-deprived for many hours. HR 120-130 RR 40. SPO2 94% is considered acceptable, but clearly, it would be desirable to achieve a higher saturation with less work of breathing and a lower oxygen concentration requirement. b-agonist bronchodilators are considered “maxed-out” and relatively contraindicated due to HR and cardiac condition.

What can you suggest? Heli-Ox, an 80% helium, 20% Oxygen mix (if used at sea level) is a low viscosity gas mixture that more easily flows through tight spaces; it lessens work of breathing promptly provided the patient can maintain oxygen saturation (or with a little oxygen enrichment).

What is the breathing pattern: It’s clearly an obstructive pattern and the patient’s habitus (short thick neck, slightly short jaw, large tongue, and pot-belly, suggest that he may have obstructive sleep apnea.

A clinical trial:  Heliox is given by  nonrebreather mask and 4LPM O2 cannula supplementation. The patient becomes comfortable, but still has some see-sawing. As you transport the patient with Heliox to the ICU, his SPO2 drops and he becomes a little dusky. You notice that he has actually relaxed enough that he has fallen asleep, obstruction has supervened but is easily corrected with a jaw thrust.

What can be done to prevent obstruction? You suggest that the patient be fitted with a custom-length Modified Nasal Trumpet (a shortened and softened endotracheal tube or long rubber tubing) to ensure airway patency behind the tongue. With this secured in place by tape and connected to the Bi-PAP™ by a 15 mm ETT connector, it will avoid the facial pressure and annoyance of a mask, the air flow will transit the nares and nose via the conduit of the fitted nasopharyngeal airway preventing mucosal irritation, the flow's seeming  intensity will be moderated by the nasal tube, there will be no full mask to trap vomiting in the airway. [Ryan, D. W., Weldon, O. G. W. & Kilner, A. J. (2002) Nasopharyngeal airway continuous positive airway pressure: a method to wean from or avoid mechanical ventilation in adults. Anaesthesia  57 (5), 475-477. doi: 10.1046/j.0003-2409.2001.02511.x  PMID: 11966558]

What is the outcome? The patient spends several days in the ICU, is never intubated, is discharged home with CPAP treatment for his diagnosis of obstructive sleep apnea.

Case Thirty-Eight: "Claustrophobic; needs preoxygenation"

    A morbidly obese patient (BMI=50)  urgently needs a sedated reduction of a dislocated total knee arthroplasty. The patient is known to have sleep apnea which is untreated because of claustrophobia  to any mask and vehemently objects to even a non-rebreathing mask for preoxygenation. Room air SPO2=90% in semi-Fowler's position. Your airway assessment also finds: NPO for ~5 hrs; small mouth with narrow opening, large tongue, uvula cannot be seen, short jaw, jowls, short thick neck, capped natural dentition in good condition, good neck mobility. You believe the patient is a potentially difficult intubation, and at risk for further desaturation with sedation possibly leading to collapse of the airway soft tissues.

The patient is too distraught to consider the need for pre-oxygenation (c.f., <http://ENW.org/Obese.htm>, so concession is made to "no mask" but acceptance is obtained for an oxygen cannula; however, a ETCO2 sampling cannula is used. This will provide real-time attention to the key physiologic parameter and will more rapidly detect the correct problem than simple pulse oximetry. Oxygen will give extra safety.

Judicious dosing with Propofol will sedate the patient incrementally overcoming mental and physical resistance to a mask without relaxing the soft tissues to the point of airway collapse; now, the patient can be  further oxygenated with the prepared anesthesia bag capable of giving Constant Positive Airway Pressure to distend the airway against collapse, using a two-handed "Triple Airway Maneuver".

Jackson-Rees.gif (15130 bytes) ETCO2 can be monitored either with the cannula under the mask or with an inline sensor to the A-Bag. Sedation is deepened safely with spontaneous breathing throughout, normal ETCO2 and SPO2  of 100%. Reduction is effected, and the patient allowed to waken (Propofol offsets rapidly) with amnesia for the events. The ETCO2 was monitored continuously against re-narcotization from analgesics now that the pain stimulus has been removed. The soft bag has shown respiratory rate and depth throughout in addition to the waveform electronic monitors.

Using Ketamine or a Ketamine/Propofol combination may spare the airway reflexes and avoid pharyngeal flaccidity that leads to obstruction. However, the key points are 1) use of waveform capnography throughout; 2) ready availability and skill in using an anesthesia bag for rescue CPAP ventilation. Bi-Level Non-Invasive Ventilation may be used at the point at which the patient accepts it. Additionally, consider having an appropriately sized SupraGlottic Airway (such as a Fastrach® Intubating Laryngeal Mask Airway, or Air-Q® through which intubation can be done) as a rescue airway/ventilatory device and intubation aid. [This paragraph inserted 10/30/2012 to reflect updated modern practice.  TT]


"I can’t breathe!" Respiratory Problems in the ED; Part II
(Cases 24 - 38)
by Tom Trimble, RN CEN ©2004
is a webarticle of "Emergency Nursing World !" [http://ENW.org]


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