What are the potential causes of a patient presenting to the Emergency Department (ED) in a gasping state, considering various underlying conditions such as asthma, Chronic Obstructive Pulmonary Disease (COPD), cardiac compromise, or toxic ingestion?

Gasping State Presentation in the Emergency Department: Differential Diagnosis and Immediate Management

A patient presenting to the ED in a gasping state should be immediately assumed to be in cardiac arrest until proven otherwise, as agonal gasping occurs in 40-60% of cardiac arrest cases and is the most commonly misinterpreted sign leading to delayed resuscitation. 1

Critical First Step: Cardiac Arrest Recognition

If the patient is unresponsive with gasping respirations, activate the emergency response system and immediately begin CPR. 1 The American Heart Association emphasizes that dispatchers and healthcare providers must be educated to recognize that agonal gasps—described variably as abnormal breathing, snoring respirations, or gasping—represent absent normal breathing and indicate cardiac arrest. 1

For Healthcare Providers:

• Check for a pulse for no more than 10 seconds 1
• If no definite pulse is felt, assume cardiac arrest and begin compressions immediately 1
• The risk of providing CPR to someone not in cardiac arrest (1-2% injury rate) is vastly outweighed by the mortality of missing true cardiac arrest 1, 2

Differential Diagnosis of Gasping Respirations

1. Cardiac Arrest (Most Critical)

• Agonal breathing represents brainstem-mediated gasping in the absence of effective cardiac output 1
• Present in 40-60% of out-of-hospital cardiac arrests 1, 2
• Immediate CPR improves survival 2- to 3-fold 1, 2

2. Severe Hypercapnic Respiratory Failure (COPD/Asthma)

• Patients over 50 years who are long-term smokers with chronic breathlessness on minor exertion should be treated as suspected COPD 1
• Respiratory rate >30 breaths/min indicates severe exacerbation requiring urgent intervention 1
• Immediate management: Provide controlled oxygen via 24% Venturi mask at 2-3 L/min targeting SpO2 88-92% pending urgent blood gas analysis 1
• Triage as very urgent and obtain arterial blood gases immediately upon arrival 1

3. Near-Fatal Asthma

• Asthma causes 5,000-6,000 deaths annually in the US, many prehospital 1
• Gasping indicates impending respiratory arrest from severe bronchoconstriction, airway inflammation, and mucous plugging 1
• The most common cause of death is asphyxia, not cardiac causes 1
• Critical indicators for intubation: Apnea, coma, persistent/increasing hypercapnia, exhaustion, and depressed mental status 3

4. Opioid Overdose

• Patients with known or suspected opioid use who have a definite pulse but gasping or no normal breathing require immediate naloxone administration 1
• Gasping represents severe respiratory depression from opioid-induced CNS depression 1

5. Drowning/Submersion

• Immediate resuscitation to restore oxygenation and ventilation is essential for survival 1
• Gasping may occur during or after water aspiration 1

6. Severe Trauma

• Patients with apnea or gasping breathing pattern (respiratory rate <6/min) require immediate endotracheal intubation 4
• Additional concerning features: hypoxia (SpO2 <90%), severe traumatic brain injury (GCS <9), hemodynamic instability (SBP <90 mmHg) 4

7. Foreign Body Airway Obstruction

• Severe airway obstruction presents with silent cough, cyanosis, inability to speak or breathe 1
• Patient may clutch neck (universal choking sign) 1
• Differentiate from cardiac arrest by witnessed choking event during eating 1

8. Hypothermia

• Unresponsive patient with gasping in cold environment should receive immediate CPR 1
• Do not wait to check temperature or rewarm before starting resuscitation 1

Immediate Management Algorithm

Step 1: Assess Responsiveness and Breathing (10 seconds maximum)

• Unresponsive + gasping/absent breathing = Assume cardiac arrest 1
• Begin CPR immediately, activate emergency response 1

Step 2: If Pulse Present but Gasping

• COPD suspected: 24% Venturi mask, target SpO2 88-92%, urgent ABG 1
• Asthma suspected: High-flow oxygen, nebulized albuterol, prepare for possible intubation 1, 3
• Opioid suspected: Naloxone administration 1
• Trauma: Rapid sequence intubation if respiratory rate <6/min 4

Step 3: Continuous Monitoring

• Pulse oximetry, ECG, blood pressure 4
• Capnography is mandatory to confirm airway placement and monitor ventilation 4
• Recheck blood gases at 30-60 minutes for COPD/asthma patients to assess for rising PCO2 or falling pH 1

Critical Pitfalls to Avoid

1. Mistaking agonal gasps for normal breathing is the most common error leading to delayed CPR and decreased survival 1, 2

2. Excessive oxygen in COPD patients increases risk of respiratory acidosis; maintain SpO2 88-92% until blood gases confirm normal pH and PCO2 1

3. Prolonged pulse checks (>10 seconds) delay chest compressions and worsen outcomes 1

4. Delaying intubation in severe asthma when signs of respiratory failure are present (persistent hypercapnia, exhaustion, depressed mental status) 3

5. Stopping CPR for more than 10 seconds to manage vomitus or other complications directly correlates with decreased survival 5

6. Using conventional ventilator settings in asthmatic patients after intubation worsens air trapping; use slower rates (10-14 breaths/min), smaller tidal volumes (6-8 mL/kg), and longer expiratory times 3