Establish Breathing

To ensure adequate oxygenation and ventilation.

Immediately evaluate:

  • Respiratory rate and effort: use of accessory muscles, nasal flaring, retractions

  • Oxygen saturation (SpO₂): via pulse oximeter

  • Chest movement symmetry and breath sounds (wheezes, crackles, diminished)

  • Skin color and mental status (cyanosis, agitation, drowsiness = hypoxia/hypercapnia)

Start oxygen immediately unless contraindicated.

Condition Oxygen Delivery FiO₂ (approx.)
Mild distress Nasal cannula 2–6 L/min 24–44%
Moderate distress Simple face mask 5–10 L/min 40–60%
Severe distress / hypoxia Non-rebreather mask 10–15 L/min 90–100%
COPD with CO₂ retention Controlled O₂ (Venturi mask 24–28%) As prescribed

Aim for SpO₂ 94–98% (or 88–92% in COPD patients with chronic CO₂ retention).

Support Ventilation (if oxygen alone is insufficient)

If breathing effort is inadequate (shallow, tiring, irregular):

  • Assist ventilation using a bag-valve-mask (BVM) with 100% O₂.

  • If patient is conscious but tiring, consider noninvasive ventilation (NIV):

    • CPAP (Continuous Positive Airway Pressure): for pulmonary edema, OSA.

    • BiPAP (Bilevel Positive Airway Pressure): for COPD exacerbation or hypercapnic failure.

If NIV fails or patient cannot protect the airway → proceed to endotracheal intubation and mechanical ventilation.

Identify and Treat the Underlying Cause

You must treat the specific cause while supporting breathing:

Cause Key Findings Immediate Treatment
Asthma/COPD Wheezing, prolonged expiration Nebulized bronchodilators (albuterol ± ipratropium), corticosteroids
Pulmonary edema Crackles, frothy sputum CPAP, nitrates, diuretics
Pneumothorax Unilateral absent breath sounds Needle decompression, chest tube
Pneumonia Fever, crackles, infiltrate Antibiotics, oxygen
Pulmonary embolism Sudden dyspnea, pleuritic pain Anticoagulation, O₂
Anaphylaxis Stridor, wheezing, hypotension Epinephrine IM, airway support, fluids

5. Monitoring and Reassessment

  • Continuous pulse oximetry, respiratory rate, and vital signs

  • ABG (arterial blood gas) if available: assess PaO₂, PaCO₂, pH

  • Reassess frequently: if oxygen or ventilation requirements are rising → escalate support.

Summary Algorithm

  1. Assess breathing

  2. Administer O₂ (start high-flow if in doubt)

  3. Assist ventilation (BVM → NIV → intubation)

  4. Treat cause

  5. Monitor and reassess continuously

Would you like me to create a flowchart or table showing this step-by-step management of breathing in respiratory distress (for quick reference or teaching use)?Dial

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Here’s a clear flowchart-style summary of how to establish and support breathing in a patient with respiratory distress — designed for quick reference in clinical or teaching settings:

🫁 Establishing Breathing in Respiratory Distress — Step-by-Step Algorithm

🔹 STEP 1 — Rapid Assessment     ↓     • Observe: respiratory rate, effort, chest expansion     • Check SpO₂ (pulse oximetry)     • Auscultate: breath sounds (wheezing, crackles, silence)     • Assess: mental status, cyanosis, ability to speak full sentences     ↓     If signs of inadequate oxygenation or ventilation → proceed to Step 2  
🔹 STEP 2 — Administer Oxygen     ↓     ▫ Mild distress (SpO₂ 90–94%): Nasal cannula 2–6 L/min (FiO₂ 24–44%)     ▫ Moderate distress: Simple face mask 5–10 L/min (FiO₂ 40–60%)     ▫ Severe distress: Non-rebreather mask 10–15 L/min (FiO₂ up to 100%)     ▫ COPD with CO₂ retention: Venturi mask 24–28% O₂ (target SpO₂ 88–92%)     ↓     Reassess after 1–2 minutes — If no improvement → Step 3  
🔹 STEP 3 — Support Ventilation     ↓     ▫ If breathing is labored but present:          → Noninvasive ventilation (CPAP/BiPAP)     ▫ If patient tiring, gasping, or apneic:          → Bag-valve-mask (BVM) ventilation with 100% O₂          → Prepare for endotracheal intubation     ↓     Confirm adequate chest rise and SpO₂ improvement  
🔹 STEP 4 — Identify and Treat Underlying Cause     ↓     ▫ Asthma/COPD exacerbation → Nebulized bronchodilators + steroids     ▫ Pulmonary edema → CPAP + nitrates + diuretics     ▫ Pneumonia → Antibiotics + O₂     ▫ Pneumothorax → Needle decompression → Chest tube     ▫ Pulmonary embolism → Anticoagulation     ▫ Anaphylaxis → Epinephrine IM + airway support  
🔹 STEP 5 — Monitoring and Reassessment     ↓     ▫ Continuous pulse oximetry     ▫ Repeat ABG if available     ▫ Reassess breathing rate, effort, SpO₂ every few minutes     ▫ Escalate support if oxygen or ventilation needs increase

✅ Key Targets

  • SpO₂: 94–98% (or 88–92% in chronic CO₂ retainers)

  • Maintain visible chest movement and adequate ventilation

  • Treat underlying cause concurrently

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Management and Determining the Cause

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