Respiratory Emergencies: A Paramedic's Clinical Guide

Respiratory Emergencies in Pre-Hospital Care

Respiratory emergencies are among the most common and time-critical calls a paramedic will attend. From acute asthma to tension pneumothorax, the ability to rapidly assess, differentiate, and treat breathing difficulties is a core clinical competency. This guide is designed for UK student paramedics working towards their degree and early clinical practice, covering the essential presentations you are likely to encounter on the road.

Primary Assessment: Don't Skip the Basics

Before reaching for a nebuliser or preparing to intubate, a structured primary survey remains your foundation. In any patient presenting with respiratory compromise, your ABCDE approach should be second nature.

When you reach 'B' — Breathing — your assessment must be methodical:

• Look: Chest rise symmetry, accessory muscle use, nasal flaring, cyanosis, tripod positioning
• Listen: Auscultate all zones bilaterally — are breath sounds present, reduced, or absent? Are there wheeze, crackles, or stridor?
• Feel: Tracheal position, chest wall tenderness, surgical emphysema
• Measure: Respiratory rate, SpO2, peak expiratory flow rate (PEFR) where appropriate

A respiratory rate outside the normal adult range of 12–20 breaths per minute is a significant finding. Tachypnoea is an early, sensitive marker of deterioration — never dismiss it as anxiety without ruling out pathology.

Common Respiratory Emergencies: Presentations and Management

Acute Severe Asthma

Asthma affects approximately 5.4 million people in the UK, making it one of the most frequent respiratory calls. Your ability to stratify severity is critical, as moderate and life-threatening asthma require different management pathways.

Key severity markers for acute severe asthma include:

• PEFR 33–50% of predicted or best
• Respiratory rate ≥25 breaths/min
• Heart rate ≥110 bpm
• Inability to complete sentences in one breath

Life-threatening features include silent chest, SpO2 below 92%, bradycardia, exhaustion, confusion, or PEFR below 33%. These patients need urgent pre-alert and rapid transport.

JRCALC-guided management includes high-flow oxygen (target SpO2 94–98%), salbutamol via nebuliser (5mg repeated as required), ipratropium bromide (0.5mg) for acute severe or life-threatening cases, and IV or oral prednisolone. In extremis, IV salbutamol or magnesium sulphate may be indicated depending on your local formulary and scope of practice.

Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

COPD exacerbations often present with increased breathlessness, productive cough, and wheeze in a patient with a known history. The key pre-hospital challenge is oxygen therapy — many COPD patients retain CO2, and uncorrected high-flow oxygen can suppress their hypoxic drive.

Target SpO2 for confirmed or suspected COPD is 88–92%, using a Venturi mask to deliver controlled oxygen concentrations. Salbutamol and ipratropium nebulisers remain first-line bronchodilators. Always check whether the patient has a rescue pack at home and whether they have already self-medicated.

Pulmonary Oedema

Acute pulmonary oedema (APO) results from fluid accumulation in the alveoli, typically secondary to left ventricular failure. Patients often present with severe breathlessness, pink frothy sputum, widespread bilateral crackles, and orthopnoea. They frequently appear terrified and exhausted.

Pre-hospital management focuses on:

• Sitting the patient upright
• High-flow oxygen to maintain SpO2 ≥94%
• Glyceryl trinitrate (GTN) spray if systolic BP is above 90 mmHg — this reduces preload and provides rapid symptomatic relief
• CPAP where available and within scope — evidence supports its use in reducing the need for intubation
• Furosemide may be indicated depending on local protocols and paramedic scope

Pneumothorax and Tension Pneumothorax

A simple pneumothorax may present with pleuritic chest pain and reduced breath sounds on the affected side. In a haemodynamically stable patient, management is largely supportive with oxygen and expedited transport.

A tension pneumothorax is a life-threatening emergency. The classic triad of absent breath sounds, tracheal deviation away from the affected side, and haemodynamic compromise (hypotension, tachycardia, distended neck veins) demands immediate intervention. In the pre-hospital environment, needle thoracocentesis at the second intercostal space, mid-clavicular line is the definitive treatment. Do not wait for hospital confirmation if clinical signs are present — this patient will arrest without intervention.

Anaphylaxis with Bronchospasm

Anaphylaxis can present with severe bronchospasm mimicking acute asthma. Always consider anaphylaxis if there is a recent exposure to a trigger, urticaria, angioedema, or cardiovascular compromise alongside respiratory symptoms. Intramuscular adrenaline (0.5mg of 1:1000) is the priority — before any other intervention.

Capnography: Your Second Pair of Eyes

End-tidal CO2 (EtCO2) monitoring via waveform capnography is increasingly standard in UK paramedic practice. It provides real-time information about ventilation, metabolic status, and perfusion. In respiratory emergencies, a rising EtCO2 in an asthmatic suggests impending respiratory failure. In a ventilated patient, it confirms tube placement and guides ventilation rate. Develop confidence in reading both the numeric value and the waveform shape — a shark-fin pattern is characteristic of bronchospasm.

When to Pre-Alert

Pre-alerting the receiving emergency department gives the clinical team time to prepare. You should pre-alert for any of the following:

• Life-threatening asthma not responding to treatment
• Suspected tension pneumothorax following needle decompression
• Acute pulmonary oedema with haemodynamic compromise
• Respiratory failure requiring ventilatory support
• Any patient with a rapidly deteriorating clinical picture

A clear, structured pre-alert using ATMIST or SBAR ensures the receiving team has the information they need before your arrival.

Key Takeaways for Student Paramedics

Respiratory emergencies reward paramedics who are systematic, calm, and confident in their clinical reasoning. Prioritise your structured assessment, understand the pathophysiology behind each condition, and know your JRCALC guidelines and local trust protocols. Treat the patient in front of you, not just the diagnosis.