Clinical Findings

Neuro: Confusion, anxiety, restlessness, AMS, somnolence, seizure w/severe hypoxemia.

Resp: Dyspnea, excessive work of breathing, tachypnea, bradypnea, use of accessory muscles, sternal retractions, wheezing, rales, stridor, coughing, flared nostrils, orthopnea.

Patterns: Cheyne-Stokes (neurological): shallow, rapid breathing with periods of apnea; apneustic (neurological) sustained inspiratory effort; Kussmaul (common in DKA): rapid, deep, and labored; bradypnea: common in opioid OD.

CV: Tachycardia, dysrhythmias, HTN, JVD, pulmonary edema (CHF).

Skin: Cyanosis, coolness, pallor, diaphoresis, hives, rash, welts.

GI/GU: Abdominal pain if associated with allergic reaction

MS: Weakness, lethargy, fatigue, exhaustion, bolt upright or tripod position to facilitate breathing.

SpO₂: Decreased oxygen saturation.

Lab/Dx: Abnormal ABG results: Hypoxemic respiratory failure, characterized by a partial pressure of arterial oxygen (PaCO₂) <60 mm Hg and a normal or low partial pressure of arterial carbon dioxide (PaCO₂), is most common and is caused by any acute disease of the lung (pulmonary edema, pneumonia); hypercapnic respiratory failure, characterized by a PaCO₂ >50 mm Hg, is associated with drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders such as asthma or emphysema.

Possible Causes: Allergic reactionanaphylaxis, aspiration, airway obstruction/choking, asthma, COPD, emphysema, drug overdose, pneumonia, pulmonary edema, pulmonary embolism, pulmonary fibrosis, pneumothorax, pulmonary arterial hypertension, adult respiratory distress syndrome (ARDS), myasthenia gravis, myxedema.

Collaborative Management

Pt may be fearful or panicked, remain with Pt and maintain calm, reassuring demeanor.

SpO₂ <90% is considered abnormal and may require immediate intervention, but some Pts (e.g., Pts with COPD) can maintain a baseline SpO₂ of 88% to 89% and are considered stable. These Pts depend on increased levels of CO₂ to maintain respiratory drive. Use oxygen judiciously when administering supplemental oxygen in presence of COPD, because excessive amounts may decrease Pt’s respiratory drive and inevitably cause clinical situation to progress to full respiratory arrest.

• Elevate HOB: Position Pt to facilitate breathing—upright, leaning forward.
• Suction oropharynx as needed to clear secretions.
• Support ABCs and be prepared to manually ventilate Pt and insert oral or nasal airway if Pt shows signs of inadequate oxygenation (e.g., AMS, cyanosis) or RR <8/min.
• Immediately activate RRT and notify HCP STAT.
• Assess SpO₂, RR, and effort, and obtain full set of VS.
• Auscultate lung fields, noting diminished or absent breath sounds, crackles, wheezing, friction rubs, or stridor.
• Administer oxygen to maintain SpO₂ >92% (see earlier ).
• If Pt hyperventilating, encourage slow, deep breathing, or, if indicated, have Pt perform pursed-lipped breathing.
• Assess for CP, nausea, leg vein tenderness, other CV symptoms.
• Assess for underlying respiratory conditions such as pneumonia.
• Ask Pt about previous episodes of SOB, what provoked it, if onset was sudden or gradual, whether SOB is made worse by lying flat.
• Assess tracheal alignment, symmetry of chest expansion, and JVD.
• Assess skin color and moistness; inspect for circumoral and nailbed cyanosis.
• Assess for contributing and/or reversible causes of respiratory distress.
• Assess Pt for signs associated with allergic reaction.
• Assess MAR for possible medication reactions.
• Obtain IV access and administer IVF as ordered.
• Administer STAT medications as ordered.
• For opioid OD:naloxone (Narcan) 0.4 mg IV/IM/IN
• For benzodiazepine OD:flumazenil (Romazicon) 0.2 mg IV/IN
• Obtain focused medical history including recent surgeries and injuries.
• Complete a focused respiratory assessment.
• Notify HCP of change in Pt status.
• Assist with intubation or chest tube placement as needed.
• Transfer to ICU if condition continues or worsens.