This protocol provides guidelines for treating respiratory emergencies in adults, including asthma, chronic obstructive pulmonary disease (COPD), pulmonary edema/congestive heart failure (CHF), and suspected pneumonia. Basic treatment involves initial assessment, oxygen therapy, monitoring, and transport. Advanced life support may include CPAP, nebulized medications, intravenous fluids and medications, and intubation as needed. Medical control consultation is advised for any questions or problems.

1. Protocol 2.2
Adult
Respiratory
Emergencies

3. ASTHMA

5. This protocol is used for patients
complaining of Dyspnea AND who are
wheezing.
Allow patients to assume a position of
comfort, when possible.
Remember a patient with a history of CHF
and no asthma history that has wheezing
should not be automatically classified as
an “asthma patient,” the more prudent
assessment would be that of CHF (cardiac
asthma).

6. Treating The Asthma
Patient
BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment Protocol 2.1.1
2. Airway Assessment/Management Protocol
2.1.2 Oxygen via nasal cannula @2 - 4 LPM to
maintain pulse ox at ≥ 94% (non-rebreather
@15 LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse oximeter.
4. Transport to designated hospital.

7. ALS LEVEL 1: PARAMEDIC ONLY
1. If severe distress consider CPAP with in-line nebulized medication may
or may not help (keep in mind, it is the medications that will work best
to break the bronchospasm)
2. Administer Albuterol (Ventolin) 2.5mg (in 2.5cc normal saline) by
nebulizer. May repeat twice PRN. DO NOT GIVE ALBUTEROL OR
IPRATROPIUM BROMIDE IF THE HEART RATE IS > 140
3. May add Ipratropium Bromide (Atrovent) 0.5 mg (0.5ml) to the first
Albuterol neb only.
4. If indicated, start IV of Lactated Ringer’s or Normal Saline at TKO
5. For persistent respiratory distress, give Methylprednisolone Sodium
Succinate (Solu-Medrol) 125mg IV.
6. For severe dyspnea, Epinephrine (1:1000) 0.4 ml IM Adult
(Peds: 0.01 ml/kg.) Caution should be used with administration of
Epinephrine when the patient has a history of hypertension or heart
disease (call med control if you have any concerns)
7. Consider need for endotracheal intubation

8. ALS LEVEL 2: MEDICAL CONTROL
1. Repeat Epinephrine (1:1000)
0.4 mg IM
2. If patient still has dyspnea
after SubQ Epi, 3 Albuterol
nebs (first with Atrovent), and
Solu-Medrol, Medical Control
may order Magnesium Sulfate
2 gms IV (mixed with 50ml of
D5W given over 10 – 15
minutes)

9. AND Dyspnea Protocol
2.2.3

12. This protocol is used for patients with a
history of emphysema and/or chronic
bronchitis that complain of dyspnea.
If at any point, the patient’s respiratory
status deteriorates, consider CPAP or
endotracheal intubation and
administration of Albuterol via the ET
tube as a mist, and transport
immediately.

13. BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment 2.1.1
2. Airway Assessment/Management Protocol 2.1.2. Oxygen via
nasal cannula @2 - 4 LPM to maintain pulse ox at ≥ 94% (non-
rebreather @15 LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse oximeter.
Treatment

14. ALS LEVEL 1: PARAMEDIC ONLY
1. If patient is in moderate to severe distress and is still alert and
cooperative, consider CPAP (with in-line nebulized medication) per
CPAP Protocol .
2. Administer Albuterol 2.5 mg in 2.5ml of normal saline and Atrovent
(Ipratropium) 0.5mg via nebulized breathing treatment.
3. Repeat Albuterol (only) every 15 minutes as needed x 3 doses total.
Discontinue therapy if patient develops marked tachycardia (HR >
140) or chest pain.
4. If signs of severe hypoventilation despite CPAP and/or Nebulized
bronchodilators: (See Airway Assessment Protocol, 2.1.2)
a. Assist ventilations with BVM with 100% oxygen.
b. Consider endotracheal intubation
5. Initiate IV lactated Ringer's or normal saline TKO.
6. For persistent respiratory distress, give Methylprednisolone Sodium
Succinate (Solu-Medrol) 125 mg IV. (NOTE: If patient already on a
steroid, give 80 mg of Solu-Medrol IV).

15. ALS LEVEL 2: MEDICAL CONTROL
1. Contact medical control or
medical director for any
questions or
problems.
2. Consider (per med control)
Valium 2-5 mg or Versed 2-4 mg
IVP for
anxiety, however patient may
then need to be intubated.

16. Pulmonary Edema/ CHF

18. This protocol is used for patients who are exhibiting signs/symptoms of pulmonary
edema – CHF including: tachypnea, orthopnea, JVD, edema, dyspnea with rales
and/or wheezing (cardiac asthma). The patient may also have diminished air
exchange. In severe case, patient may be pursed lip breathing. Other treatment for
the causes of pulmonary edema-CHF should be considered (e.g. supraventricular
tachycardia, myocardial infarction and cardiogenic shock).
Protocol 2.2.4

19. BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment Protocol.
2.1.1
2. Airway Assessment/Management
Protocol.2.1.2. Put patient in position
of comfort. Oxygen via nasal cannula @2 -
4 LPM to maintain pulse ox at
≥ 94% (non-rebreather @15 LPM if SpO2 <
90%).
3. Attach cardiac monitor and pulse
oximeter.

20. ALS LEVEL 1: PARAMEDIC ONLY
1. Administer CPAP (if available). Titrate to 10cm of pressure (see
CPAP Protocol)
2. If patient’s respiratory status deteriorates (fatigues, does not respond to
CPAP, obvious persistent distress), assist ventilations with BVM with
100% oxygen and consider endotracheal intubation. If patient has endstage
disease and has previously expressed to family (verbally or in
writing) he/she does not want to be intubated, and then continue
assisting with BVM or CPAP.
3. Initiate IV lactated Ringer’s or Normal Saline TKO.
4. If systolic BP > 100 mm Hg; give Nitroglycerine 0.4mg sublingual
(spray or tablet) followed by Nitroglycerin paste 1 inch to chest wall
Avoid if patient used Viagra, Cialis, Levitra or other ED drugs. (May
repeat sublingual Nitro every 3 minutes up to 3 doses total if patient is
hypertensive or has chest pain).
5. Do 12 Lead EKG. Transmit if abnormal and time permits

21. ALS LEVEL 2: MEDICAL CONTROL
1. Lasix 40-80 mg IV.
2. Consider Morphine Sulfate slow IV in
2mg increments titrate to systolic
BP > 100 (or signs of respiratory
depression) up to10 mgs. Carefully
monitor blood pressure and respirations.
Be prepared to reverse with
Narcan if needed.
3. Contact medical control or medical
director for any concerns or
questions.

22. Pneumonia (Suspected)

23. Protocol 2.2.5
Patients complaining of dyspnea should be suspected of
having pneumonia when they present with fever, productive
cough, and possible pleuritic chest pain, history of being
bedridden, known immune-compromise, diabetes, elderly
and lung sounds indicative of consolidation (rales and/or
rhonchi with egophony over area of consolidation).

24. BASIC LEVEL: EMT and PARAMEDIC
1. Initial Patient Assessment Protocol
2.1.1
2. Airway Assessment/Management
Protocol 2.1.2. Oxygen via nasal
cannula @2 - 4 LPM to maintain pulse ox
at ≥ 94% (non-rebreather @15
LPM if SpO2 < 90%).
3. Attach cardiac monitor and pulse
oximeter
4. Check temperature if able

25. ALS LEVEL 1: PARAMEDIC ONLY
1. Consider CPAP (per CPAP protocol) for severe dyspnea/air hunger. It
may or may not help but will not harm.
2. Initiate IV lactated Ringer’s or Normal Saline at 125ml/hr. If patient
hypotensive (systolic < 90 mm Hg) and/or tachycardic (HR > 110) bolus
with 1- 2 liters of IV fluid in 250ml increments until systolic BP > 90 mm
Hg (20 ml/kg for children). Recheck vital signs and lung exam inbetween
each increment. Discontinue bolus if signs of pulmonary edema
or development of respiratory distress.
3. If dyspnea noted, administer Albuterol 2.5 mg in 2.5ml of normal saline
and Atrovent (Ipratropium) 0.5mg via nebulized breathing treatment.
Do not give if HR ≥ 140
4. Repeat Albuterol (only) every 15 minutes as needed x 3 doses total.
Discontinue therapy if patient develops marked tachycardia (HR > 140)
or chest pain.
5. If signs of severe hypoventilation despite CPAP and/or Nebulized
bronchodilators: (See Airway Assessment Protocol 2.1.2)
a. Assist ventilations with BVM with 100% oxygen.
b. Consider endotracheal intubation
6. AVOID USE OF DIURETICS!!

26. ALS LEVEL 2: MEDICAL CONTROL
1. Notify medical control or medical director for any problems
or concerns.