Sometimes a patient will arrive at the Emergency Department in respiratory distress. This is manifested many ways: the patient may be wheezing loudly on expiration, they may have slight shortness of breath, or they may appear to have no air movement at all despite frantic efforts to breathe.
Respiratory Distress or Failure
Respiratory distress is not difficult to recognize. The patient has labored breathing, and may exhibit “air hunger,” known as “dyspnea.” Their respiratory rate may be elevated, and their ability to breath is often hampered by a supine position.
Addressing the underlying cause should determine appropriate treatment for respiratory distress. A patient with a severe asthma attack should be treated with nebulized medications and steroids; the patient in congestive heart failure may have wet lungs full of fluid, which will respond to a diuretic; a patient with a tension pneumothorax must receive a chest tube to release the pressure trapped in the chest; patients with emphysema, or COPD, often require supplemental oxygen — though it’s important to note that with too much supplemental oxygen, the drive to breath is suppressed.
After attempting to treat respiratory distress in the Emergency Department setting, it is important to evaluate the patient’s response to treatment in a timely manner. Although some information is gained from the pulse oximeter the nurse will have placed upon the patient’s fingertip, this simply reads the saturation of oxygen in the blood stream. For various reasons, that oxygenated blood may not be getting to the lungs, or the carbon dioxide released from deoxygenated blood may build up with a failure to provide adequate ventilation.
Acute respiratory failure often occurs among patients with heart failure, pneumonia, or chronic obstructive pulmonary disease. Respiratory failure can also be a result of pulmonary contusions or pneumothorax. Asthma can quite quickly lead to respiratory failure in the severe asthmatic. Choking can obstruct the airway and when the patient becomes unresponsive, it is time to address ways to oxygenate them.
Respiratory failure must be addressed immediately. It is defined by difficulty breathing and certain parameters indicating the partial pressure of oxygen and carbon dioxide in the arterial system. It’s not important to understand the mechanisms of homeostasis of oxygen and carbon dioxide, as they can be complex. The body has many compensatory mechanisms, and it is the job of the physician to obtain an arterial blood sample and analyze the results for signs of respiratory failure.
Ventilation and Intubation
At that point, if a patient is in respiratory failure, they must receive assisted ventilations with supplemental oxygen. Usually, after ventilating with a bag-valve mask device proves inadequate, some advanced airway is required. In most settings, this involves endotracheal intubation. This is the term for inserting a breathing tube into the trachea, and supplying oxygen directly to the lungs. In an emergency situation, the endotracheal tube may be hooked up to a bagging device, which delivers oxygen, while a respiratory therapist is called to set up a ventilator.
Problems with endotracheal intubation can be devastating. The anatomy of the oropharynx, or the inside of the mouth and back of the throat, can be difficult to identify in some patients, particularly those who are obese, or have short necks. Some doctors may not be adequately trained to perform intubations routinely, simply because they stood by during residency and didn’t participate actively in enough intubations under supervision.
The esophagus lies directly behind the trachea. It is a narrow muscular column. When looking in the throat to find the landmarks, which mark the entrance to the trachea, the physician must find the vocal cords, and the tube must pass through those cords, which form a triangular opening, into the trachea. If the tube is not seen to go through the cords, it may well be lodged in the esophagus, and oxygen will be delivered to the stomach.
Doctors sometimes commit intubation errors, especially if the anatomical landmarks are in some way distorted. The tissues around the trachea may become swollen and edematous with multiple intubation attempts. Intubation attempts interrupt oxygenation provided by “bagging” the patient, and they should brief, because lack of oxygen quickly leads to cell death.
A study in Anesthesia and Analgesia in 2004 revealed that complications increased significantly with the number of attempts at intubation. Some of these complications have far-reaching consequences. They include aspiration of gastric contents into the lungs, which causes aspiration pneumonia, often associated with a high morbidity and mortality rate. Hypoxemia, or inadequate delivery of oxygen was associated with 70% of the patients who experienced greater than two intubation attempts.
11% of patients in the study who had experienced greater than two attempts at intubation suffered cardiac arrest. Pre-arrest bradycardia, or abnormally slow heart rate, is another complication.
Difficulty with intubation can result in brain damage and death. While some patients may be difficult to intubate, the American Society of Anesthesia recommends limitation of laryngoscopic attempts at intubation to three. There are other alternatives, which must be attempted if the patient has a difficult airway and the physician is unable to intubate quickly.
All physicians in an Emergency Department setting should be trained in some alternative methods of providing emergency airways. These include surgical procedures in the ER, utilizing fiberoptic bronchoscopy, and calling for anesthesia or surgical consultants. Some physicians are reluctant to call for help, and instead will try to futilely place an adjunctive airway in an emergency, losing valuable time and putting the patient at risk of brain injury or cardiac arrest.
If you or a family member has experienced harm from failure of a physician to secure an airway in respiratory failure or cardiac arrest, you may have been the victim of medical negligence. You should contact a medical malpractice attorney for evaluation of your case, as you may have certain recourse to damages under the law. Call us at 312-527-4500 for a free consultation.