Respiratory Arrest

Definition of Terms

Normal breathing (adults): 12–16 breaths per minute with a tidal volume of 8–10 mL/kg.

Tachypnea: > 20 breaths per minute.

Bradypnea: < 12 breaths per minute.

Hypoventilation: Patients present with poor oxygenation and ventilation parameters that necessitate the use of oxygen supplementation or assisted ventilations, such as a bag-mask device.

Types of Respiratory Problems

The three primary types of respiratory problems are respiratory distress, respiratory failure, and respiratory arrest. The characteristics and other important information about each type of problem are outlined in the following sections.

Respiratory Distress

CHARACTERISTICS: 

• Abnormal respiratory rate 
• Increased respiratory effort (nasal flaring, retractions) or inadequate respiratory effort (bradypnea or hypoventilation) 
• Abnormal airway sounds (stridor, wheezing, grunting, crackles), tachycardia, pale and cool skin, altered level of consciousness, or use of accessory muscles for breathing

SEVERITY:

Respiratory distress may be mild, moderate, or severe. Severe respiratory distress indicates impending respiratory failure and is recognized by²: 

• Increased respiratory effort 
• Visible changes in skin color 
• Altered mental status

Severe respiratory distress can cause bluish discoloration of the extremities, especially in the fingers and lips.

Related Video – How to Manage Respiratory Arrest on an Adult

Respiratory Failure

CHARACTERISTICS: 

Respiratory failure is the end stage of respiratory distress. It requires interventions such as assisted ventilations and medications.³ There will be an increase in carbon dioxide (hypercapnia) and a decrease in oxygen concentration (hypoxia).

SPECIAL CIRCUMSTANCES: 

Patients with lesions in the central nervous system may be in respiratory distress without showing any significant signs due to disruptions to the autonomic controls.

Respiratory Arrest

CHARACTERISTICS: 

Respiratory arrest is the complete absence of breathing. It is treated with assisted ventilation with a bag-mask device that can deliver a volume of 500–600 mL.

WARNING: 

Avoid excessive ventilation because studies have shown that it can cause poor outcomes. Excessive ventilation causes gastric insufflation, regurgitation, and aspiration of stomach contents. 

Gastric inflation compresses the structures and organs in the mediastinum. The resulting increase in intrathoracic pressure compromises the venous return to the heart, diminishing cardiac output.

Respiratory arrest is treated with assisted ventilation using a bag-mask device.

Read: Multidisciplinary Approach to Postcardiac Arrest Care

Systematic Assessment in Respiratory Arrest

The following explains how a provider should go about the systematic assessment in respiratory arrest.

BLS Assessment (Remember DRS ABCD)

• D (danger) = ensure scene safety.
• R (response) = check if the patient is responsive; if not,
• S (shout for help) = activate the emergency response system, call for help, and have someone retrieve an automated external defibrillator (AED).
• A (airway) = check for any obstruction in the patient’s airway. That may be a foreign object, blood, or other secretions.
• B (breathing) = check for spontaneous breathing. Do not exceed 10 seconds when checking for breathing and pulses. 
• C (circulation) = check for a pulse. Central pulses, such as the carotid pulse, are more easily felt than peripheral pulses, such as the radial pulse.
• D (defibrillate) = this step is UNNECESSARY in respiratory arrest because the patient’s pulses are intact, indicating a perfusing rhythm.

A foreign object can obstruct the patient’s airway, leading to choking and respiratory arrest.

Primary Assessment

A (airway) = The provider should maintain the patient’s airway by performing maneuvers such as the head tilt-chin lift or jaw thrust. Patients in respiratory arrest will have a pulse but are not breathing. Chest compressions and the use of an AED are not necessary at this point.

B (breathing) = The rescuer should give assisted ventilations — one rescue breath every 5–6 seconds. Mouth-to-mouth ventilations should only be performed with a barrier device. Medical devices, such as an oropharyngeal airway, nasopharyngeal airway, or a bag-mask device, can be used to assist in giving ventilations. The provider must make sure not hyperventilate the patient.

C (circulation) = The provider should check for a pulse every 2 minutes and make sure not to exceed 10 seconds when checking for a pulse.⁴ 

If a pulse is present, the provider continues rescue breathing for 2 minutes and checks for a pulse again, repeating the cycle until emergency medical services (EMS) arrives. If the pulse is absent or if the provider is unsure if there is a pulse within 10 seconds, then they should begin high-quality cardiopulmonary resuscitation (CPR).

D (disability) = Some communities have adapted treatment protocols for opioid use. If available, give naloxone if the patient is suspected or known to have overdosed on opioids. Many medical professionals (and laypersons) always carry a naloxone kit with them because opioid overdose is so prevalent.

Related Video -Understanding the Steps of the Primary Assessment

When a patient is in respiratory arrest, they have a pulse but are not breathing or are struggling to breathe. The medical provider must understand the types of respiratory problems and how to assess and treat the patient.