Airway & Respiratory, Patient Care

Consider All Differentials for Respiratory Distress

Issue 11 and Volume 39.

At 11:52 p.m., the county sheriff’s dispatcher tones out Medic 41 to an address in a rural subdivision about 15 miles from their small town’s EMS station. Dispatch advises an out-of-breath male is in the back bedroom and may not be able to unlock the front door. Since the fire department doesn’t have any trained EMS providers, dispatch also assigns a sheriff’s deputy to the call in the event the EMS crew needs to force entry to the house.

The crew arrives at the address almost the same time as the deputy. There appear to be two houses on the property, both with the same address. The medics and deputy knock on the door of the larger house, whose resident states she didn’t call 9-1-1. The medics and deputy knock on the locked door of the second house but receive no response. The deputy forces it open.

The EMS crew makes it to the back bedroom of the home, where they find an approximately 70-year-old male in a tripod position at the foot of his bed. He’s breathing with the aid of a nasal cannula on a home oxygen generator at a rate of two liters per minute. The patient gasps for breath between each word as he tells the crew, “Can’t … breathe!” The patient weighs approximately 330 pounds.

Prehospital Treatment
The paramedic immediately auscultates the lungs and hears little air movement. His EMT partner hooks the patient to the capnography and pulse oximetry functions on the cardiac monitor and then transfers the patient’s oxygen to their oxygen cylinder. Due to the confined quarters of the residence, the crew was unable to bring the stretcher inside.

The cardiac monitor shows a heart rate of approximately 94 in a sinus rhythm, a blood pressure of 104/48, and a pulse oximetry of 86% while on the oxygen at four liters per minute. The capnography waveform is normal.

The patient’s wife is able to provide some of the patient’s prior history, including several previous heart attacks, chronic obstructive pulmonary disease, hypertension and congestive heart failure (CHF). She also provides a list of his medications, which include lisinopril with HCTZ (hydrochlorothiazide), nitroglycerin, albuterol, Advair (fluticasone) and simvastatin. She says her husband has been ill for several days and hasn’t been compliant with his prescription medications for the past three days. He went to the back room to see if he could sleep sitting up and told her not to disturb him. In fact, she didn’t know he called for EMS assistance.

In part because of the critical nature of the call, the size of the patient and the difficulty in accessing the back bedroom, the crew contacts dispatch by radio and requests additional personnel. Shortly after the tones go out, a volunteer first responder and an off-duty paramedic who lives in town are en route.

Meanwhile, the paramedic asks his partner and the deputy to get the continuous positive airway pressure (CPAP) kit and a stair chair. While this is occurring, the paramedic turns the oxygen flow up to 15 liters per minute by nasal cannula for passive oxygenation and prepares for a possible emergent intubation. As the team begins assembling the CPAP device, the two additional responders arrive and the team maneuvers the patient onto the stair chair to move the patient to the ambulance.

The providers move the patient to the stretcher. At this point, the patient’s head is beginning to bob and he seems to be confused and lethargic. Both paramedics agree that the patient’s level of consciousness is insufficient to maintain compliance with CPAP therapy and agree that a crash airway situation exists.

They ask the EMT to get the video laryngoscope, connect the powered suction, obtain a rescue airway from the shelf and pre-oxygenate the patient. As one of the paramedics prepares the laryngoscope, the other draws up the appropriate rapid sequence intubation medications per protocol: 450 mg of ketamine (3 mg/kg at 150 kg) and 150 mg of rocuronium (1 mg/kg at 150 kg). He also prepares 5 mg of midazolam per protocol.

After both medics confirm the medications and dosages, the second establishes IV access via an 18-gauge catheter to the left forearm. After pre-oxygenating the patient, the other paramedic administers the ketamine, then the rocuronium. He uses the video laryngoscope to pass a 7.5 mm endotracheal (ET) tube and captures the image of the tube passing through the vocal cords onto the digital memory card. They then confirm placement via waveform end-tidal carbon dioxide capnography and secure the tube with a commercial device. Next, the patient is sedated with midazolam. The two paramedics agree they should both attend to the patient and ask the EMT to initiate emergency transport to a large community hospital on the outskirts of the nearest large city, about 35 miles away.

En route, the patient’s condition remains relatively unchanged, especially since he’s been sedated. The crew also obtains a 12-lead ECG, which doesn’t reveal any acute ST segment changes. The relative hypotension, especially in consideration of previous patient encounters where he’s routinely noncompliant with his antihypertensives, cause both providers to rapidly eliminate the possibility of a CHF exacerbation and thus rule out nitrate or diuretic therapy. The primary paramedic also obtains an axillary temperature of 103.5 degrees F. Based on this, combined with the patient’s relative hypotension, the paramedics suspect the possibility of sepsis and begin administering a fluid bolus. They contact the hospital via radio and advise the hospital of their treatment and the possible concern of sepsis, requesting that the hospital have a respiratory therapist in the ED on their arrival.

Hospital Treatment
The patient is brought into the primary resuscitation room where the emergency physician on duty evaluates the patient. A chest X-ray is ordered for confirmation of ET tube placement. Upon viewing the film, the physician determines the patient has pneumonia. A dosage of Levaquin (levofloxacin) is ordered via IV pump along with several fluid boluses. The patient remains on the ventilator and is admitted to the intensive care unit. After a course of antibiotic therapy, the patient is weaned from the ventilator and returns home several weeks later after discharge from the hospital to a skilled nursing facility for rehabilitation.

Discussion & Clinical Pearls
Pneumonia is a relatively common but overlooked cause of respiratory distress. Pneumonia is a lung infection that causes fluid to collect in the alveoli of the lungs. It causes inflammation, which may cause dyspnea, fever, chills, chest pain, chest wall pain or coughing.1

Several key clinical points bear mentioning. First, the entire EMS team practiced crew resource management throughout the course of the call. The initial crew recognized the need for additional personnel for both patient movement and patient treatment. The assisting first responder recognized the patient’s condition had deteriorated to the point where CPAP was contraindicated. Both paramedics recognized the patient’s condition might require both of them to attend to the patient during transport and they additionally worked together as a team, particularly during the rapid sequence intubation.

Also, while treating the patient, the providers used passive oxygenation with the nasal cannula to boost the patient’s oxygen saturation prior to intubation. The nasal cannula can even remain on the patient during the intubation attempt to maintain oxygen saturation. High-flow oxygen through the cannula has been shown to maintain saturations in excess of 95% during intubation.2

Finally, the EMS team identified the possibility of sepsis when they obtained the patient’s temperature and noted the relatively low blood pressure (particularly for a patient with a history of hypertension).

This case presented challenges in assessment and diagnosis, especially considering the patient’s history of respiratory diseases and possible other comorbidities. Even with obtaining the patient’s history from the patient, family, and his medications, several likely differential diagnoses exist. The use of waveform capnography can help rule in or out the possibility of a reactive airway disease process. This case also illustrates that, even in a patient with a history of several respiratory disease processes, a new cause of respiratory failure can occur. Again, like any form of medicine, clinically competent and progressive emergency medical care is dependent on a through physical assessment and history-taking.

1. Abrahamson L, Mosesso V Jr., editors: Advanced medical life support: An assessment based approach. Elsevier Mosby: St. Louis, Mo., pp. 124–126, 2011.
2. Levitan R. (Dec. 9, 2010.) No desat! Emergency Physicians Monthly. Retrieved July 11, 2014, from