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Managing Respiratory Arrest

Respiratory arrest is the cessation of breathing, and it may occur for a variety of reasons. Regardless of the cause, it is a life-threatening situation which requires immediate management. When a patient goes into respiratory arrest, they are not getting oxygen to their vital organs and may suffer brain damage or cardiac arrest within minutes if not promptly treated.

In some cases, you may be able to identify impending respiratory arrest before it happens. Signs of an impending respiratory arrest include increased work of breathing, which simply means that the patient is working hard for each breath. Eventually, they will deplete their reserves and they will not be able to maintain the effort it is taking to breathe. Respiratory arrest will occur in these patients without prompt intervention.

Additional signs of impending respiratory arrest are gasping, paradoxical breathing movements, cyanosis and intercostal retractions.  Some patients may also become confused or excessively sleepy due to hypoxia or increased carbon dioxide levels. In most cases, if signs of respiratory failure are identified early, treatment can be implemented to prevent complete respiratory arrest.

Remembering the Basics

If you are first on scene for a respiratory arrest, it can be a stressful situation and it can be easy to forget the basics. The first thing you will need to do is assess responsiveness. If the patient is unresponsive (or is minimally responsive with gasping or abnormal breathing) open the patient’s airway and begin manually ventilating the patient, then call for help. If you are in the hospital and a code blue has not already been activated, hit the code button. A pulse may be present initially, but be prepared to begin chest compressions should the patient deteriorate into cardiac arrest.

Open the patient’s airway and provide positive pressure ventilation with a bag-mask. In most cases, unless the patient has a neck or spinal cord injury, you can open the airway using the head-tilt chin lift method. In the hospital setting, ensure your bag-mask is attached to the oxygen flow meter and the oxygen is turned all the way up.

The use of an oral airway can be helpful in order to prevent the tongue from blocking the airway. An oral airway will cause gagging, so be sure to use one only if the patient is unconscious. In the semi-conscious patient you may use a nasal airway.

Make sure you have a tight seal against the patient’s face when you are holding the mask over the patient’s mouth and nose. Avoid ventilating too quickly. Sometimes in a high stress situation the adrenaline takes over, and it’s easy to hyperventilate the patient. Remember that ventilating too fast or with too large a tidal volume can increase intrathoracic pressure, decrease cardiac output, decrease venous return to the heart and cause gastric distension. Provide breaths at a rate of 10 to 12 breaths/minute in the adult patient in respiratory arrest (1 breath every 5 to 6 seconds).

If you see chest rise with each breath, you are providing adequate ventilation. Attach a pulse oximeter to monitor heart rate and oxygen level while you continue to bag.

Advanced Airway Management

After providing positive pressure ventilation with a bag-mask, the patient may spontaneously begin to breathe on his/her own. If this occurs, be sure the patient’s breathing is adequate, administer supplemental oxygen and continue to monitor the patient.

If the patient does not begin to breathe on their own, the patient will need to be intubated. While the intubation equipment is being set up, continue to ventilate the patient using the bag-mask.

Prior to the patient being intubated, you may need to suction the mouth and oropharynx in order to remove any secretions so that the vocal cords can be visualized. Confirmation that the trachea has been successfully intubated may be initially indicated by chest rise. In addition, place an end tidal CO2 device, which will indicate the presence of carbon dioxide during exhalation. A chest x-ray can be done as soon as possible to confirm tube placement. At this point, the patient will need to be placed on a mechanical ventilator.

Determine and Treat the Underlying Cause

There are many causes of respiratory arrest. For example, drug overdoses can depress the central nervous system and lead to respiratory arrest. Certain neuromuscular diseases can cause fatigue, which eventually leads to the cessation of breathing. Airway obstruction, metabolic disorders and strokes can also lead to respiratory arrest. Knowing the patient’s history, their chief complaint and medications they are taking can help determine the underlying cause.

In addition, blood tests such as arterial blood gases, a complete blood count, electrolytes and others may provide clues as to cause of the respiratory arrest. A chest x-ray should be performed. Once the pieces of the puzzle are in place, a diagnosis and underlying cause of respiratory arrest can often be identified and treated.

Article Sources

Farzan, Sattar, MD, FACP, FCCP A Concise Handbook of Respiratory Diseases. Prentice Hall 1997. Accessed July 2014

The Merck Manual. Overview of Respiratory Arrest. http://www.merckmanuals.com/professional/critical_care_medicine/respiratory_arrest/overview_of_respiratory_arrest.html Accessed July 2014