What are the immediate management steps for common pulmonological emergencies?

Immediate Management of Common Pulmonological Emergencies

The immediate management of pulmonological emergencies requires rapid assessment, prompt intervention, and a systematic approach to restore oxygenation and ventilation while addressing the underlying cause.

Respiratory Arrest and Cardiopulmonary Resuscitation

Initial Assessment and Actions

• Immediately check responsiveness and breathing
• If unresponsive with no normal breathing or only gasping:
  • Activate emergency response system
  • Begin chest compressions at a rate of at least 100/minute and depth of at least 2 inches (5 cm) in adults 1
  • Allow complete chest recoil after each compression
  • Minimize interruptions in compressions

Airway Management

• Open airway using head tilt-chin lift maneuver (jaw thrust if trauma suspected) 1
• Provide rescue breathing with 30:2 compression-to-ventilation ratio for single rescuers
• Apply high-flow oxygen when available
• Use waveform capnography to confirm proper airway placement and monitor ventilation quality 1

Foreign Body Airway Obstruction (Choking)

Recognition

• Look for signs of severe airway obstruction: inability to speak, silent cough, cyanosis, universal choking sign (clutching neck) 1

Management

1. For conscious adult victims:

   • Deliver abdominal thrusts (Heimlich maneuver) until object is expelled or victim becomes unconscious

2. For unconscious victims:

   • Begin CPR starting with chest compressions
   • Look in mouth before each ventilation attempt and remove visible objects
   • Avoid blind finger sweeps which may push object deeper 1

Drowning

Immediate Actions

1. Remove victim from water by fastest means available
2. Begin CPR immediately, prioritizing rescue breathing (5 initial breaths)
3. Give 5 cycles (about 2 minutes) of CPR before leaving to activate emergency response if alone 1

Special Considerations

• Do not perform Heimlich maneuver routinely (no evidence water acts as obstructive foreign body)
• Consider spinal immobilization only if signs of injury, alcohol intoxication, or history of diving into shallow water 1

Tracheostomy Emergencies

Accidental Decannulation

1. Call for help immediately (experienced personnel like anesthesiologists or ENT surgeons)
2. Apply oxygen via face mask to upper airway AND directly to stoma site
3. Attempt to replace tracheostomy tube with:
   • Same size tube first
   • One size smaller if unsuccessful (should be available at bedside) 2

Blocked Tracheostomy Tube

1. Remove any attachments (speaking valves, caps, humidifiers)
2. Remove inner cannula if present and replace with clean one
3. Attempt to pass suction catheter
4. If unsuccessful, replace entire tracheostomy tube 1

Equipment Requirements

• Bedside emergency equipment must include:
  • Spare tracheostomy tubes (same size and one size smaller)
  • Suction equipment with appropriate catheters
  • Lubricating jelly
  • Tracheostomy tapes/ties
  • Waveform capnography 1

E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

Initial Assessment

• Evaluate for hypoxemia, respiratory distress, and hemodynamic stability
• Consider hospital admission for patients with:
  • O₂ saturation <95% on room air
  • Respiratory distress
  • Comorbidities that compromise cardiopulmonary reserve 1

Management

1. Discontinue all e-cigarette or vaping product use
2. Consider empiric antimicrobial therapy according to guidelines
3. Consider corticosteroids (use with caution due to risk of worsening respiratory infections)
4. Ensure follow-up within 48 hours of discharge for outpatients 1

Hypothermia with Respiratory Compromise

Assessment and Management

1. Begin chest compressions immediately if unresponsive with no normal breathing
2. Do not wait to check temperature or for rewarming to start CPR
3. Remove wet clothes, insulate patient, and shield from wind/cold
4. If possible, ventilate with warm, humidified oxygen
5. Avoid rough movement during transport 1

Critical Airway Management Principles

Oxygenation Priority

• Always prioritize oxygenation over securing a definitive airway unless required for oxygenation 2
• Apply high-flow oxygen via appropriate devices to both face and tracheostomy stoma when applicable

Monitoring

• Use continuous pulse oximetry but recognize its limitations (delayed indicator of ventilation problems)
• Employ waveform capnography whenever possible for all airway interventions 2
• Monitor vital signs closely including respiratory rate, heart rate, and blood pressure

Common Pitfalls to Avoid

1. Delaying CPR to check for pulse (start compressions within 10 seconds if pulse not definitely felt)
2. Relying solely on pulse oximetry without assessing ventilation
3. Multiple blind insertion attempts through tracheostomy stoma (can create false passages)
4. Ignoring a patient who complains of breathing difficulty even if objective signs are absent 2
5. Administering excessive oxygen without addressing ventilatory support in patients with chronic CO₂ retention

Warning Signs of Impending Respiratory Failure

• Increased work of breathing (accessory muscle use, paradoxical breathing)
• Altered mental status
• Inability to speak in full sentences
• Decreasing oxygen saturation despite supplemental oxygen
• Fatigue and decreased respiratory effort (ominous sign of impending arrest)

Remember that early recognition and intervention in pulmonological emergencies significantly improves outcomes. When in doubt, call for help early and focus on maintaining oxygenation while preparing for definitive management.