Respiratory Emergencies: A Paramedic's Clinical Guide

Respiratory Emergencies in Pre-Hospital Care

Respiratory emergencies are among the most frequently encountered and time-critical calls in UK pre-hospital practice. From acute severe asthma to tension pneumothorax, the ability to rapidly assess, differentiate, and treat respiratory compromise is a core clinical competency for any paramedic. This guide provides a structured, JRCALC-aligned overview of the key conditions you will face in practice and in your assessments.

The Primary Survey: Don't Skip the Basics

Before focusing on a specific diagnosis, your primary survey remains your foundation. In any patient presenting with breathing difficulty, you must systematically assess:

• Airway: Is it patent? Are there signs of obstruction, stridor, or secretions?
• Breathing: Rate, depth, effort, symmetry, SpO2, and auscultation findings.
• Circulation: Skin colour, capillary refill time, heart rate, and blood pressure.
• Disability: AVPU or GCS — hypoxia rapidly impairs consciousness.
• Exposure: Look for accessory muscle use, tracheal deviation, surgical emphysema, or rashes.

Your SpO2 target in most respiratory emergencies should be 94–98%, with a revised target of 88–92% for patients at risk of hypercapnic respiratory failure, such as those with confirmed COPD — in line with current JRCALC guidelines.

Acute Severe Asthma

Asthma affects approximately 5.4 million people in the UK, and acute exacerbations are a common emergency call. Recognising severity is critical, as life-threatening asthma can be subtle in presentation.

Severity Classification

• Moderate: PEFR 50–75% best or predicted, no features of severe asthma.
• Severe: PEFR 33–50%, SpO2 <92%, RR >25, HR >110, inability to complete sentences.
• Life-threatening: PEFR <33%, silent chest, cyanosis, bradycardia, hypotension, exhaustion, or altered consciousness.

Pre-Hospital Management

Your immediate priority is bronchodilation and oxygenation. JRCALC-guided management includes:

1. Salbutamol 5mg via nebuliser (oxygen-driven at 6–8 L/min for severe or life-threatening cases).
2. Ipratropium bromide 0.5mg via nebuliser if severe or life-threatening.
3. IV or IM hydrocortisone 200mg, or oral prednisolone if the patient can swallow.
4. Consider IV magnesium sulfate 2g over 20 minutes in life-threatening cases (within scope or via physician support).
5. Early notification to receiving hospital and prepare for RSI if the patient is deteriorating rapidly.

Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

COPD exacerbations frequently result in 999 calls, particularly in winter months. Patients often present with increased breathlessness, worsening cough, and changes in sputum. Key clinical considerations include:

• Avoid high-flow oxygen without indication — use a 28% Venturi mask initially and titrate to SpO2 88–92%.
• Salbutamol and ipratropium nebulisers are first-line bronchodilators.
• Assess for signs of respiratory fatigue — rising CO2 and falling pH indicate impending respiratory failure.
• Non-invasive ventilation (NIV/BiPAP) is a definitive treatment in hospital; communicate the need urgently during pre-alert.

Be vigilant for concurrent pneumonia, pneumothorax, or pulmonary embolism, all of which can precipitate an apparent COPD exacerbation.

Pulmonary Embolism

Pulmonary embolism (PE) is a potentially fatal condition that is notoriously difficult to diagnose pre-hospital. It should be on your differential for any patient presenting with acute breathlessness, pleuritic chest pain, or unexplained tachycardia — particularly in those with risk factors such as recent surgery, immobility, malignancy, or pregnancy.

Clinical Features

• Sudden-onset dyspnoea and tachypnoea
• Pleuritic chest pain (worse on inspiration)
• Haemoptysis
• Tachycardia and hypotension in massive PE
• Signs of DVT (unilateral leg swelling, calf tenderness)

Pre-hospital management is largely supportive: high-flow oxygen, IV access, fluid resuscitation in the haemodynamically compromised patient, and urgent transport with pre-alert. In cardiac arrest secondary to massive PE, consider extended CPR, as thrombolysis in hospital may restore return of spontaneous circulation.

Pneumothorax and Tension Pneumothorax

A simple pneumothorax may cause mild breathlessness and unilateral reduced air entry. A tension pneumothorax is a life threat requiring immediate intervention. Classic signs include:

• Severe respiratory distress
• Absent breath sounds on the affected side
• Tracheal deviation away from the affected side (a late sign)
• Hypotension and raised JVP (Beck's triad variant)
• Cardiovascular collapse

Treatment is needle thoracostomy (or finger thoracostomy in intubated patients) at the second intercostal space, mid-clavicular line, or the fourth or fifth intercostal space, anterior axillary line — according to local protocol and your scope of practice. Do not delay for further assessment if tension pneumothorax is suspected in a deteriorating patient.

Anaphylaxis with Respiratory Compromise

Anaphylaxis can present primarily as severe bronchospasm, particularly in asthmatic patients. If a patient presents with acute wheeze, urticaria, angioedema, or a known allergen exposure, consider anaphylaxis early. First-line treatment is intramuscular adrenaline 0.5mg (1:1000) into the anterolateral thigh, repeated at 5-minute intervals if there is no improvement. Do not delay adrenaline administration.

Documentation and Handover

Accurate clinical documentation and structured handover are vital in respiratory emergencies. Use the SBAR (Situation, Background, Assessment, Recommendation) format for pre-alerts and verbal handovers. Include SpO2 trends, treatment given and response, PEFR values where recorded, and changes in conscious level. Clear communication directly influences the speed and appropriateness of in-hospital treatment.

Key Takeaways for Student Paramedics

• Always use a structured primary survey before anchoring on a diagnosis.
• Oxygen targets differ — 94–98% for most patients, 88–92% for hypercapnic COPD.
• Treat severity, not just diagnosis — asthma can kill quickly.
• Tension pneumothorax requires immediate needle decompression — do not wait.
• PE is a diagnosis of exclusion pre-hospital; support and transport urgently.
• Adrenaline first in anaphylaxis — every time.