1
Scene Size-Up & BSI ▼
- Gloves, eye protection (respiratory secretions)
- Scene safety — assess environment, hazards, exposures
- Note patient position (tripod position = severe distress)
- Look for inhalers, home O2, nebulizer, CPAP equipment
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2
Initial Assessment — Work of Breathing
- General impression: Ability to speak in full sentences?
- Accessory muscle use: Neck, intercostal, subcostal retractions
- Respiratory rate: Normal 12-20. <8 or >30 = critical
- SpO2: Target ≥ 94% (≥ 88-92% for known COPD)
- Nasal flaring, pursed-lip breathing, paradoxical chest movement
- Mental status: Agitation/confusion = impending failure
- Skin: Cyanosis (central = severe), pallor, diaphoresis
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Impending Respiratory Failure?
Silent chest, RR <8 or >30, SpO2 <85%, altered LOC, unable to speak
Silent chest, RR <8 or >30, SpO2 <85%, altered LOC, unable to speak
YES — IMMEDIATE
BVM ventilation. Jaw thrust/OPA/NPA. ALS NOW. Consider supine if collapses.
NO — Continue
Administer O2, assess breath sounds, continue systematic evaluation
🎵 Step 3 — Breath Sound Assessment
Select Predominant Breath Sound
Wheezing
Bilateral
Crackles
Bilateral / Basilar
Absent / Diminished
Unilateral
Stridor
Upper airway
Clear / Normal
Consider other cause
4
SAMPLE History & Risk Factors ▼
- Hx of asthma/COPD? — how often intubated/ER visit?
- Cardiac hx? — CHF, prior pulmonary edema, CABG
- Medications: Inhalers (albuterol, steroids), diuretics, ACE inhibitors
- Allergies / exposures: Anaphylaxis trigger?
- Trauma: Rib fractures, penetrating chest?
- DVT risk: Recent surgery, immobility, pregnancy, cancer → PE
- Pregnancy: Altered physiology — lower reserve
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5
OPQRST — Respiratory Focus ▼
- Onset: Sudden (PE, PTX, anaphylaxis) vs gradual (CHF, COPD exac)
- Position: Orthopnea (worse lying flat) → CHF; improved upright
- Provocation: Exertion → cardiac/PE; allergen → anaphylaxis/asthma
- Quality: Chest tightness (asthma), inability to get air (COPD), air hunger
- Severity: Able to speak? Single words only = severe
- Radiation: Associated chest pain character (pleuritic? crushing?)
- Time: Duration, prior episodes, last ER visit for this problem
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📊 Step 6 — Interactive Differential
🧭 Refine Differential
Additional Findings (select all that apply)
Select breath sound type above to generate differential
🩺 Step 7 — Management
Positioning & O2 Delivery
BLS Position: Sitting upright / tripod. Never force supine unless unconscious. Semi-recumbent for COPD.
BLS Oxygen Delivery — titrate to SpO2 ≥ 94% (≥ 88% COPD):
| Device | Flow Rate | FiO2 | Indication |
|---|---|---|---|
| Nasal Cannula | 2–6 L/min | 28–44% | Mild hypoxia, COPD |
| Simple Mask | 6–10 L/min | 35–55% | Moderate hypoxia |
| Non-Rebreather | 10–15 L/min | 60–95% | Severe hypoxia |
| BVM (ventilate) | 15 L/min | ~100% | Apnea / near-apnea |
| CPAP/BiPAP | Per device | Variable | CHF, COPD — ALS |
💨 Bronchodilator — Albuterol
BLS Assist patient's own albuterol inhaler if prescribed and in their possession (scope varies by state/agency). 2 puffs via spacer.
ALS Nebulized albuterol 2.5mg in 3mL NS (may repeat × 2), ipratropium 0.5mg for COPD, IV/IM epinephrine for anaphylaxis.
COPD: Avoid excess O2. Target SpO2 88–92%. High-flow O2 may suppress hypoxic drive and cause respiratory depression. Use NC or controlled flow.
🚨 ALS Intercept Criteria
🔴 ALS Request — Any of the following:
- RR < 8 or > 30, SpO2 < 90% on O2
- Silent chest (no air movement = immediate failure)
- Altered mental status / unable to maintain airway
- Suspected tension pneumothorax (needle decompression)
- Anaphylaxis with airway compromise (epinephrine)
- Acute pulmonary edema / CHF (CPAP, nitrates, furosemide)
- Foreign body airway obstruction unrelieved by BLS
- Hemodynamic instability (BP < 90)