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Figure 13–1.
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Management of severe respiratory distress.

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Assess Severity and Give Immediate Necessary Care

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Patients in severe respiratory distress should receive simultaneous evaluation and therapy (see Figure 13–1). Providing and maintaining an adequate airway is the first consideration. Quickly assess the severity of distress by noting the patient's general appearance. Patients struggling to breathe demonstrate a greater use of chest and accessory muscles than the normal quiet use of the diaphragm. Any patient with severe respiratory distress should receive immediate oxygen supplementation during assessment and treatment. Rapidly perform a focused examination of the oropharynx, neck, lungs, heart, chest, and extremities. A plain film chest X-ray (CXR) with PA and lateral views, if possible, provides valuable information and should be obtained as soon as possible.

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Assess Adequacy of Oxygenation

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Pulse Oximetry

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Bedside pulse oximeters measure the percent saturation of oxygen in capillary blood. Pulse oximetry is particularly useful during procedural sedation and during attempts at endotracheal intubation because of the real-time availability of the information. However, this information is incomplete because pulse oximeters do not measure the pCO2 or detect the presence of hypoventilation leading to respiratory acidosis.

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Arterial Blood Gases

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Arterial blood gases provide, in essence, the same information about arterial oxygen saturation as does pulse oximetry, but are necessary to provide valuable information about the effectiveness of ventilation. The blood gas provides measurement of pH, pO2, and pCO2. Arterial blood gases should be obtained in patients who are in severe respiratory distress, especially if pulse oximetry identifies that they require high concentrations of oxygen.

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Cardiac Arrest

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Clinical Findings

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In unresponsive patients, check for airway patency and properly position the head and jaw to open the airway (Chapter 9). Evaluate respiratory effort and assist ventilations if inadequate. Ventricular fibrillation results in rapid loss of consciousness usually within 5–10 seconds. Such patients usually become apneic but may have perfunctory respiratory effort while unconscious. Such agonal breathing will be shallow and ineffective. It is important to recognize the situation as a primary cardiac event. The treatment is immediate defibrillation.

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Basic and advanced life support is covered in Chapter 9.

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Severe Upper Airway Obstruction

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See also Chapter 10.

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Clinical Findings

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Unless the patient has progressed to apnea unwitnessed, high-grade upper airway obstruction is usually obvious from pronounced stridorous respirations. Retractions of the supraclavicular and suprasternal areas of the chest indicate that there is significant obstruction. Patients with complete airway obstruction will not be able to breathe or speak. Patients may have a visible swelling ...

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