General Approach to All Patients

Airway Emergencies - Adult Dyspnea

Basic Life Support

  • Supplemental 100% oxygen

Advanced Life Support

  • Full ALS Assessment and Treatment
  • Observe for signs of impending respiratory failure; refer to Respiratory Failure section if needed
    • Hypoxia (O2 sat < 90) not improved with 100% Oxygen
    • Poor ventilatory effort (increasing ETCO2 not improved with treatment)
    • Altered mental status/ decreased level of consciousness
    • Inability to maintain patent airway
  • Begin CPAP if initial symptoms severe
    • Based on presentation, use manufacturer settings for Asthma/COPD or CHF
    • Brief interruptions to administer medications are acceptable

Acute Bronchospasm (wheezing or history of asthma or COPD)

  • Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer
    • Repeat Albuterol (Proventil)/Ipratropium Bromide (Atrovent) X 2 if wheezing persists
  • Methylprednisolone (Solumedrol) 125 mg IV if wheezing persists after 1st nebulizer
  • If not improving, Magnesium Sulfate 2 grams IV in 100 ml DSW over 10-15 minutes
    • Contraindicated if history of renal failure
    • Do not use if CHF suspected
  • If SEVERE respiratory distress and wheezing persists after above:
    • Epinephrine 1:1,000 0.3 mg IM (prior permission from Medical Control if patient >55 years old or known to be on B blockers)

Acute Pulmonary Edema (history of CHF, pedal edema, elevated SBP)

  • Nitroglycerin 0.4 mg spray or tablet SL, every 5 minutes
    • Contraindicated if systolic BP < 90 mm Hg
    • Contraindicated if use of a Phosphodiesterase-5 (PDE5) inhibitor use within last 24 hours (Viagra or Levitra); 48 hours for Cialis
  • For bronchospasm (wheezing) associated with Acute Pulmonary Edema
    • Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer
      • Repeat Albuterol (Proventil)/Ipratropium Bromide (Atrovent) X 2 if wheezing persists
  • For hypotension (systolic BP < 90 mmHg)
    • Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90 mm Hg


  • Spinal immobilization if indicated
  • Consider CPAP for patients with significant dyspnea or hypoxia
  • Protect from heat loss
  • Patients may develop delayed onset respiratory symptoms
  • Refer to appropriate protocol if cardiac arrest present

Foreign Body Obstruction Suspected

  • Perform obstructed airway procedures per BLS standard
    • Attempt suction and removal with Magill forceps using direct visualization
    • Observe for signs of impending respiratory failure
    • If unconscious or unresponsive:
      • Give a series of 30 chest compressions then inspect for object in mouth prior to attempting breaths
      • If unsuccessful after one series of compressions and ventilations, attempt to directly view object with laryngoscope and remove with Magill forceps

Respiratory Failure

Basic Life Support

  • If suspicion of trauma, maintain C-spine immobilization
  • Suction all debris, secretions from airway
  • Supplemental 100% oxygen, then BVM ventilate if indicated

Advanced Life Support

  • Monitor end-tidal CO2 (capnography) and oxygen saturation continuously
  • Follow algorithm if invasive airway intervention is indicated (ETT or LTA):
    • Apnea
    • Decreased level of consciousness with respiratory failure (i.e. hypoxia [O2 sat <90] not improved by 100% oxygen, and/or respiratory rate < 8)
    • Poor ventilatory effort (with hypoxia not improved by 100% oxygen)
    • Unable to maintain patent airway

Bag Mask Ventilate Flowchart

  • Effective bag valve mask ventilation is an acceptable endpoint
  • Place oral-gastric tube via insertion port on LTA; attach to low continuous suction
  • Attempt cricothyrotomy only after all other ventilation methods have failed

Confirmation of Placement and Effectiveness of Ventilation (ETT or LTA)

Capnography/ETCO2 Monitoring:

  • Digital capnography (waveform) is the system standard for ETCO2 monitoring and continuous ETCO2 monitoring is a mandatory component of invasive airway management
  • Immediately after placing an ETT or LTA capnography shall be applied to confirm proper placement
    • Proper placement is indicated by the presence of a continuous alveolar waveform on capnography
    • If an alveolar waveform is not initially present, or disappears after 3-5 breaths (i.e. flat-line), remove the ETT or LTA and proceed to the next step in the algorithm
  • With the exception of on-scene equipment failure, patients should not be switched from digital capnography to a colorimetric device for monitoring end-tidal C02
  • If capnography is not available due to serious on-scene equipment failure, apply a colorimetric ETCO2 detector capable of continuous ETCO2 monitoring (much less reliable)
  • If continuous expired ETCO2 cannot be detected by either of the above methods, the invasive airway device must be removed, and the airway managed noninvasively

Additional Measures

  • Assess epigastric sounds, breath sounds, and chest rise and fall
  • Record tube depth and secure in place using a commercial tube holder
  • Utilize head restraint devices (i.e. “head-blocks”) or rigid cervical collar and long spine board immobilization as needed to help secure airway device in place