Ineffective Breathing

The dispatcher wakes you from a sound sleep with a traditional morning wake up call. You made it back after taking a refusal on an anxious person several hours prior, and you can already smell the coffee as you wake from your sleepy state. The shift is almost over, and home awaits after your relief.

Seconds later, the sound you hear is not so pleasant. The pre-alert warning and associated major medical warble tone… “respond to a six echo one, forty year old female barely breathing.” As you have come to expect from these early morning calls, you figure you will most likely be working a cardiac arrest as “barely breathing” is most often agonal respirations. The scenario of a cardiac arrest runs into your mind as you anticipate the worst possible scenario.

You hit the door with your medical jump bag while the engine crew follows with the cot, monitor, and oxygen bag. The cardiac arrest you anticipated was much different, but almost as bad. You encounter an obese woman sitting on the edge of the bed, she is taking quick, short breaths. Her husband tells you she has been doing this since 3am, which is about 3 hours. She tells you in one and two word sentences she has asthma and has no home treatments.

She appears extremely tired, her skin is cool and dry, with cyanosis around her lips and nail beds. Face face is a little puffy and her jugular veins are distended. Her respiratory effort is elevated, using all her muscles to breathe. Her lungs are diminished and it doesn’t sound like she is moving any air at all, you hear slight crackles at the bases but can’t be sure. She is tachycardic at a rate around 130. Her belly is distended and hard and her legs and feet have hard non-pitting edema. Her blood pressure is 206/186, HR 128, RR 40 and fatigued, oxygen saturation is difficult to obtain due to her cold extremities, but reads at 36%.

Her husband tells you she has been released from the hospital within the past 2 weeks for cardiac problems, and her medication list includes amlodipine, furosemide, glipizide, and another medication where the bottle is too worn to read. Due to her extreme condition, you forgo a 12 lead at the point of care in order to begin immediate respiratory intervention.

What kind of history do you draw from the medication list? What is your diagnosis and what do you handle first, and how?

  • Redbull34th

    High flow O2 at 15 LPM, EKG, High dose NTG, CPAP, possibly Captopril and NTG paste if not contraindicated. If she doesn’t tolerate the CPAP, perhaps nasal intubation with IV Midazolam. Aggressive airway management.

  • Redbull34th

    High flow O2 at 15 LPM, EKG, High dose NTG, CPAP, possibly Captopril and NTG paste if not contraindicated. If she doesn’t tolerate the CPAP, perhaps nasal intubation with IV Midazolam. Aggressive airway management.

  • I like the suggestions by Redbull34th.

    It is good to ask respiratory distress patients about what breathing problems they have had before. I don’y like to ask the patient open ended questions, but give them a list to nod (Yes) or shake (No) his/her head to. I finish with, Is there anything I have not mentioned? to avoid missing things.

    For this patient, it seems as if she has both a CHF and asthma histories. Does this feel more like her asthma? Her CHF? Something else? A combination?

    This does appear to be a combination of CHF and asthma, so I would consider some nebulized albuterol, but the CPAP is more important, if a nebulizer cannot be set up to work with the CPAP. Methylprednisolone IV and magnesium IV are other asthma treatments that can be very helpful with unstable asthma patients.

    The high-dose NTG should provide some improvement if this is CHF, but not be harmful if this is asthma. IV NTG would be best with CPAP. The CPAP should work for both CHF and asthma. Albuterol does not appear to be harmful for cardiac asthma, but there is not great research on this. Methylprednisolone and magnesium should not be harmful if it is CHF.

  • I like the suggestions by Redbull34th.

    It is good to ask respiratory distress patients about what breathing problems they have had before. I don’y like to ask the patient open ended questions, but give them a list to nod (Yes) or shake (No) his/her head to. I finish with, Is there anything I have not mentioned? to avoid missing things.

    For this patient, it seems as if she has both a CHF and asthma histories. Does this feel more like her asthma? Her CHF? Something else? A combination?

    This does appear to be a combination of CHF and asthma, so I would consider some nebulized albuterol, but the CPAP is more important, if a nebulizer cannot be set up to work with the CPAP. Methylprednisolone IV and magnesium IV are other asthma treatments that can be very helpful with unstable asthma patients.

    The high-dose NTG should provide some improvement if this is CHF, but not be harmful if this is asthma. IV NTG would be best with CPAP. The CPAP should work for both CHF and asthma. Albuterol does not appear to be harmful for cardiac asthma, but there is not great research on this. Methylprednisolone and magnesium should not be harmful if it is CHF.

  • Dublinbayarea

    Smells of CHF, responded to older woman than age in story. heavy drinker, tachy, edema, and short of breath. i was training with Berkeley fire. oxygen,ekg, pack her up. i wouldnt waste time thinking its only asthma with the hard edema, find out if the mystery med is nitro from hubby and bounce.

  • Dublinbayarea

    Smells of CHF, responded to older woman than age in story. heavy drinker, tachy, edema, and short of breath. i was training with Berkeley fire. oxygen,ekg, pack her up. i wouldnt waste time thinking its only asthma with the hard edema, find out if the mystery med is nitro from hubby and bounce.

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