Respiratory Emergencies: A Paramedic's Clinical Guide

Respiratory Emergencies in Pre-Hospital Care

Respiratory emergencies are among the most time-critical presentations a paramedic will encounter. From acute severe asthma to life-threatening pulmonary embolism, the ability to rapidly assess, differentiate, and intervene is a core clinical competency. This guide covers the key conditions, assessment frameworks, and management priorities aligned with JRCALC guidelines and NHS pre-hospital practice.

Systematic Assessment of the Breathless Patient

Before reaching for a treatment, a structured assessment is essential. In pre-hospital care, time is limited, but a methodical approach prevents missed diagnoses and inappropriate interventions.

Use the ABCDE framework as your foundation, with particular attention to the following during the respiratory assessment:

• Look: Respiratory rate, use of accessory muscles, chest wall symmetry, cyanosis, pursed-lip breathing, tracheal deviation
• Listen: Wheeze (typically expiratory in asthma/COPD), stridor (upper airway obstruction), crackles (pulmonary oedema, pneumonia), absent breath sounds (pneumothorax)
• Feel: Tracheal position, surgical emphysema, chest expansion
• Measure: SpO2, respiratory rate, peak expiratory flow rate (PEFR) where appropriate, end-tidal CO2 if capnography is available

A full history using SOCRATES or SAMPLE combined with focused questioning — onset, severity, associated symptoms, triggers, and medication history — will guide differential diagnosis.

Asthma: Recognition and Management

Asthma remains one of the most common respiratory emergencies in the UK. The British Thoracic Society (BTS) severity classification is a useful reference point for pre-hospital clinicians:

• Moderate: PEFR 50–75% best or predicted, increasing symptoms
• Acute severe: PEFR 33–50%, RR >25, HR >110, inability to complete sentences
• Life-threatening: PEFR <33%, SpO2 <92%, silent chest, bradycardia, exhaustion, confusion
• Near-fatal: Raised PaCO2 or requiring mechanical ventilation

Pre-hospital management of acute severe asthma follows JRCALC guidance:

1. Sit the patient upright and apply high-flow oxygen (target SpO2 94–98%)
2. Salbutamol 5mg nebulised, driven by oxygen — repeat as required
3. Ipratropium bromide 0.5mg nebulised in acute severe or life-threatening cases
4. Consider IV or IM access for hydrocortisone 200mg or oral prednisolone 40–50mg if able to swallow
5. IV magnesium sulphate 2g over 20 minutes may be considered in life-threatening cases
6. Urgent transfer with pre-alert to receiving hospital

A silent chest is an ominous finding — it does not indicate improvement. It suggests air movement is so severely compromised that wheeze can no longer be generated.

COPD: Balancing Oxygen and Hypercapnic Drive

Chronic Obstructive Pulmonary Disease (COPD) exacerbations are a frequent call for UK paramedics, particularly in older patients with a significant smoking history. The key clinical challenge is oxygen titration.

Patients with severe, long-standing COPD may rely on hypoxic drive to breathe. Administering high-flow oxygen uncritically risks suppressing this drive and precipitating hypercapnic respiratory failure. JRCALC recommends a target SpO2 of 88–92% for patients with known or suspected COPD, using a 28% Venturi mask as a starting point.

Management priorities include:

• Titrated oxygen to achieve SpO2 88–92%
• Nebulised salbutamol and ipratropium bromide
• Oral prednisolone or IV hydrocortisone
• Consider non-invasive ventilation (NIV/CPAP) if available and the patient is alert enough to tolerate it
• Early hospital notification, particularly if the patient is tiring or showing signs of type II respiratory failure

Pulmonary Embolism: The Diagnostic Challenge

Pulmonary embolism (PE) is a potentially fatal condition that frequently mimics other respiratory presentations. Pre-hospital diagnosis is challenging, but clinical suspicion should be raised when a patient presents with sudden-onset dyspnoea, pleuritic chest pain, haemoptysis, or unexplained tachycardia — particularly in the context of recent surgery, prolonged immobility, pregnancy, or known malignancy.

The Wells Score can aid pre-hospital risk stratification, although definitive diagnosis requires CTPA in hospital. Pre-hospital management is largely supportive:

• Position patient comfortably — typically sitting upright
• High-flow oxygen to correct hypoxaemia
• IV access and fluid resuscitation if haemodynamically compromised
• Prepare for rapid deterioration — a massive PE can cause cardiac arrest
• In cardiac arrest secondary to PE, consider extended CPR and early hospital notification for potential thrombolysis

Pneumothorax and Tension Pneumothorax

A spontaneous pneumothorax may present with sudden pleuritic chest pain and reduced breath sounds on the affected side. In a haemodynamically stable patient, observation and hospital transfer is appropriate.

A tension pneumothorax, however, is an immediate life threat. Clinical features include:

• Tracheal deviation away from the affected side (late sign)
• Absent breath sounds unilaterally
• Hypotension and raised JVP
• Rapidly deteriorating SpO2 and haemodynamic instability

Do not wait for X-ray confirmation. Pre-hospital needle thoracostomy (second intercostal space, mid-clavicular line, or the fourth/fifth intercostal space, anterior axillary line) followed by finger thoracostomy if trained and within scope is the definitive pre-hospital intervention. JRCALC supports this in the context of traumatic tension pneumothorax or cardiac arrest with suspected aetiology.

Acute Pulmonary Oedema

Acute pulmonary oedema (APO) presents with severe dyspnoea, pink frothy sputum, widespread bilateral crackles, and a history consistent with left ventricular failure. Patients are often hypertensive and very distressed.

JRCALC-aligned pre-hospital management includes:

• Sit the patient upright
• CPAP (5–10 cmH2O) if available — strong evidence for pre-hospital benefit
• GTN spray (400 micrograms sublingually) repeated if systolic BP >90 mmHg — reduces preload effectively
• Furosemide IV 40–80mg if IV access is established and protocols support it
• Continuous monitoring and urgent transfer

Key Documentation and Handover Points

Accurate handover is as important as clinical management. When handing over a respiratory patient, ensure you communicate using a structured tool such as SBAR (Situation, Background, Assessment, Recommendation). Include:

• Onset and progression of symptoms
• Observations on scene and trends over time
• Interventions performed and patient response
• Relevant past medical history and current medications
• Your working diagnosis and any clinical concerns