Breathing Difficulty

Symptom-Based Respiratory


Asthma / COPD


  • Albuterol (Proventil) or Duoneb via HHN. May repeat to a total of 3 treatments
  • For first treatment may add ipratropium bromide or use Duoneb
  • For asthma only, consider Epinephrine 1:1000 0.3 ml IM if patient is unable to breathe in HHN
  • Consider CPAP if available
  • Consider 60 mg Prednisone PO or Solumedrol 125mg IV

Tension Pneumothorax


  • Expose chest and clean procedure area on skin
  • Use commercial device or long, large bore IV catheter and needle (10-14 gauge; 3 inch 10 gauge preferred)
  • Insert the device or IV needle and catheter over the top of the rib of the second or third intercostal space in the midclavicular line


  • Insert the device or IV needle and catheter over the top of the rib of the fifth or sixth intercostal space in the midaxillary line


  • If a tension pneumothorax is present, a rush of air may be heard
  • Remove the needle from the catheter and leave the plastic catheter in place
  • Decompression may be supported with a large syringe, multiposition (3-way stopcock) valve, commercial attachment, or left to open air

Airway Obstruction


  • Have victim cough forcefully if possible
  • If victim cannot speak or cough, perform Heimlich maneuver until successful or patient unconscious;
  • If unconscious, perform CPR and attempt BVM ventilations while preparing to intubate
  • Use laryngoscope to visualize airway; if object visible, use Magill forceps or suction to remove
  • If object not visible, intubate the airway; push object down the right mainstem bronchus to obstruct right lung and ventilate the left lung

Anaphylactic Reaction


  • Epinephrine 0.3ml 1:1000 IM if either hypotension or severe respiratory distress is present
  • Albuterol (Proventil) 2.5mg in 2.5ml NS via HHN if wheezing or bronchospasm is present
  • If hypotension infuse 1 liter NS IV WO rate.
  • Benadryl 25-50mg IV/IM/PO; may be given without preceding Epinephrine in mild cases
  • If hypotension persists, consider push dose epinephrine (5-20 mcg every 2-5 minutes; discontinue IM dosing)
  • Persistent symptoms w/ known β blockers consider Glucagon IM/IV

Congestive Heart Failure


  • CPAP if available
  • Evaluate for contraindications to nitroglycerin:
    • Systolic BP <100 mmHg
    • Viagra/sildenafil in the last 24 hours
    • Levitra/vardenafil in the last 48 hours
    • Cialis/tadalafil in the last 72 hours
    • Medications for pulmonary hypertension (ex: Flolan, Revatio, Adcirca)
  • Assess vitals, acquire 12-lead ECG and establish IV
  • Consider Nitroglycerin administration as described below (If inferior MI evident on ECG, contact medical control prior to Nitroglycerin administration):
  • 0.4 mg SL every 5 min X3 for MILD symptoms (HR<100, SBP 100-150, RR<25) or;
  • 0.8 mg SL every 5 min X3 for MODERATE or SEVERE symptoms (HR>100, SBP >150, RR>25) or;
  • Topical Nitroglycerin:
  • 1″ for SBP 100-150
  • 1.5″ for SBP 150-200
  • 2″ for SBP >200
  • Reassess blood pressure after each Nitroglycerin dose; do not readminister if SBP<100 mmHg
  • Monitor LOC & respiratory status; do not readminister if status changes that cause concern for aspiration based on patient’s clinical status