NREMT Respiratory Emergencies & Oxygen Delivery 2 — Questions and Answers

Question 1: A patient with asthma presents with wheezing, accessory muscle use, and a prolonged expiratory phase. SpO2 is 91%. Which position is MOST beneficial for this patient?

Supine with legs elevated
Prone position
High Fowler's position (sitting upright) (Correct answer)
Lateral recumbent position

Correct answer: High Fowler's position (sitting upright)

Sitting upright (High Fowler's position) reduces the work of breathing by allowing diaphragm descent and reducing abdominal pressure on the chest, maximizing respiratory effort in a patient with obstructive lung disease.

Positioning is a simple but important intervention for patients in respiratory distress. High Fowler's position (sitting upright at 90 degrees) is preferred for dyspneic patients because it: allows the diaphragm to descend more fully during inspiration; reduces abdominal visceral pressure on the inferior lung bases; facilitates use of accessory muscles in the neck and thorax; and reduces venous return (preload reduction), which can be beneficial in cardiogenic pulmonary edema. For patients with obstructive lung disease (asthma, COPD), the prolonged expiratory phase and air trapping create a state of dynamic hyperinflation — the lungs become increasingly overinflated with each breath because air cannot escape fast enough. Sitting upright helps by allowing maximal diaphragm excursion. Many patients with significant respiratory distress will instinctively assume the tripod position (leaning forward, hands on knees) — this position should be respected as it typically optimizes the patient's own respiratory mechanics. Prone positioning is not appropriate for acute asthma. Supine positioning with legs elevated (Trendelenburg) increases venous return and diaphragm displacement, worsening breathing in a respiratory patient. Lateral recumbent may be used for specific situations (patients with excessive secretions) but is not optimal for obstructive lung disease.

Question 2: What is the primary sign that distinguishes pneumothorax from pulmonary edema during physical assessment?

Presence of cyanosis
Unilateral absent or decreased breath sounds on the affected side (Correct answer)
Respiratory rate above 20 breaths per minute
SpO2 below 94%

Correct answer: Unilateral absent or decreased breath sounds on the affected side

Pneumothorax causes absence or decrease of breath sounds on the affected side due to lung collapse or air in the pleural space. Pulmonary edema produces bilateral crackles from fluid in alveoli.

Auscultation of breath sounds is a critical differentiating tool for respiratory emergencies. In a pneumothorax (air in the pleural space causing lung collapse), breath sounds are absent or significantly decreased on the affected side because air cannot enter the collapsed or displaced lung. This unilateral finding is a key distinguishing feature. In cardiogenic pulmonary edema (fluid backing up into the alveoli from left heart failure), breath sounds are typically bilateral with diffuse crackles (rales) — the classic 'wet' breathing sound from fluid in the alveoli. The patient often presents with orthopnea (difficulty breathing when flat), pink frothy sputum, JVD, and peripheral edema. Other physical findings that help distinguish pneumothorax: tracheal deviation toward the unaffected side (suggests tension pneumothorax), asymmetric chest rise, subcutaneous emphysema (crackling sensation under the skin), and hyper-resonance to percussion on the affected side. Tension pneumothorax — a life-threatening emergency where air under pressure cannot escape the pleural space — adds signs of cardiovascular compromise: tachycardia, hypotension, and JVD. Needle decompression of tension pneumothorax is within some EMT and AEMT scopes of practice and is immediately life-saving.

Question 3: A non-rebreather mask at 15 L/min can deliver approximately what fraction of inspired oxygen (FiO2)?

21% (room air)
35-50%
60-80% (Correct answer)
Up to 90-100%

Correct answer: 60-80%

A properly fitting non-rebreather mask with a reservoir bag fully inflated at 15 L/min can deliver approximately 60-80% FiO2. Perfect 100% FiO2 is not achievable with a simple mask due to potential air leakage.

Understanding the approximate FiO2 delivered by various oxygen delivery devices is essential for appropriate oxygen titration. Room air contains 21% oxygen. Nasal cannula (1-6 L/min) delivers approximately 24-44% FiO2 (each L/min adds approximately 4% above 20%). Simple face mask (5-10 L/min) delivers approximately 35-60% FiO2. Non-rebreather mask (10-15 L/min) delivers approximately 60-80% FiO2 in a well-fitting mask with reservoir bag maintained. Bag-valve-mask with supplemental oxygen and reservoir (10-15 L/min) can deliver 90-100% FiO2. The non-rebreather mask has one-way valves on the exhalation ports that prevent room air from being inhaled during inspiration. The reservoir bag pre-fills with 100% oxygen, and the patient inhales from this bag. However, a perfect seal is rarely achieved, some exhalation valves allow minimal room air entrainment, and the bag may not fully refill between breaths at very high respiratory rates — so 100% FiO2 is not reliably achieved in practice. For patients requiring high FiO2 who are breathing spontaneously, the non-rebreather is the device of choice. When a patient requires FiO2 above what the NRB can provide, or when they cannot maintain adequate spontaneous breathing, positive pressure ventilation with BVM is indicated.

Question 4: A patient presents with severe difficulty breathing, is unable to speak in complete sentences, and has use of all accessory muscles. SpO2 is 86%. Which intervention takes priority?

Obtain a complete SAMPLE history before beginning treatment
Apply supplemental oxygen and prepare for possible assisted ventilation immediately (Correct answer)
Auscultate breath sounds for 2 minutes to determine the cause
Contact medical direction before any intervention

Correct answer: Apply supplemental oxygen and prepare for possible assisted ventilation immediately

An SpO2 of 86% with severe respiratory distress requires immediate oxygen therapy and preparation for ventilatory support. Life-threatening hypoxia is treated immediately — history and auscultation follow initial stabilization.

The principle of 'treat as you find' applies here. An SpO2 of 86% represents severe hypoxia — the patient is approaching the point of respiratory failure. At the level of 86%, the oxyhemoglobin dissociation curve is steep: small further decreases in SpO2 correspond to dramatic drops in oxygen content. Respiratory failure and cardiac arrest can occur rapidly. Immediate interventions: apply high-flow oxygen via non-rebreather mask at 15 L/min; position the patient upright; prepare bag-valve-mask for assisted ventilation if the patient deteriorates; request ALS backup; and prepare for rapid transport. If the patient's respiratory effort decreases or they become less responsive, begin assisted ventilation without delay. History and detailed auscultation are important but secondary to immediate oxygenation. A brief, targeted assessment — Is the patient breathing? How hard? What is the SpO2? — drives the initial intervention. A 30-second PAT plus SpO2 gives enough information to begin oxygen therapy. As the patient is being treated, the EMT can gather history from bystanders, look for medications and medical alert bracelets, and auscultate breath sounds to guide further treatment decisions.

Question 5: Which of the following is a sign of adequate bag-valve-mask (BVM) ventilation?

Epigastric sounds with each ventilation
Visible chest rise with each breath delivered (Correct answer)
Resistance felt in the bag that never changes
SpO2 that remains unchanged after 2 minutes

Correct answer: Visible chest rise with each breath delivered

Visible chest rise with each ventilation is the primary confirmation of adequate BVM ventilation. Epigastric sounds indicate ventilating the stomach (gastric inflation), which is a complication, not a confirmation of adequate ventilation.

Bag-valve-mask ventilation is effective when it delivers air into the lungs rather than the stomach. The primary indicator of effective BVM ventilation is bilateral, symmetric chest rise with each delivered breath. Additional confirmatory signs include: improvement in skin color (from cyanotic to pink), audible bilateral breath sounds when auscultated over the lateral chest walls (not over the epigastrium), improvement in SpO2, and a 'feel' of compliance — the bag should be easy to squeeze and the chest should rise visibly. Epigastric sounds (gurgling in the abdomen) during ventilation indicate gastric insufflation — air is being delivered to the stomach rather than the lungs. This most commonly occurs when the airway is not properly opened, the mask seal is inadequate, or ventilation rate and volume are excessive. Gastric distension from inflation can cause regurgitation and aspiration, and impairs diaphragm movement. If epigastric sounds are heard, stop ventilation, reposition the airway, improve mask seal, and retry. Proper BVM technique requires: one EMT to maintain the airway and mask seal (two hands on the mask using EC clamp technique for single-rescuer, or two hands for seal while partner ventilates with two-person BVM), jaw thrust to open airway, sufficient volume to cause visible chest rise (500-600 mL for average adult), and rate of 10-12 breaths per minute for adults (not too fast — hyperventilation reduces coronary perfusion pressure during CPR).

Question 6: A patient with COPD is in respiratory distress. The EMT hears wheezing on auscultation and the patient states they ran out of their inhaler. Per protocol and with medical direction approval, the EMT should consider:

Administering the patient's expired nitroglycerin tablets
Assisting with or administering albuterol nebulizer treatment (Correct answer)
Administering high-flow oxygen only without any medications
Waiting for ALS to arrive before any intervention

Correct answer: Assisting with or administering albuterol nebulizer treatment

Albuterol nebulizer is indicated for bronchospasm in COPD exacerbation. Many EMS systems carry albuterol and have protocols for its use in respiratory distress. Medical direction contact is appropriate when the patient does not have their own inhaler.

COPD exacerbations involve a component of bronchospasm in many patients, making beta-2 agonist bronchodilator therapy (albuterol) a primary treatment. If the patient's own prescribed albuterol inhaler is not available, many EMS systems carry albuterol for nebulization as part of their drug formulary. In these cases, the EMT (or AEMT) can administer albuterol per standing orders or after contacting medical direction. The standard nebulized albuterol dose is 2.5 mg in 3 mL normal saline, delivered by nebulizer over 5-10 minutes. In-line nebulization (placing the nebulizer in the BVM circuit or oxygen mask) allows simultaneous oxygen delivery. Ipratropium bromide (Atrovent), an anticholinergic bronchodilator, is often combined with albuterol in COPD (but less so in asthma) and may be available in some ALS systems. Oxygen therapy should be applied concurrently, targeting SpO2 88-92% in known COPD patients. Withholding all intervention and waiting for ALS is inappropriate when the patient is in active distress and the EMT has tools available. Each minute of bronchospasm without treatment results in worsening respiratory fatigue and potential respiratory failure. Transport should be initiated promptly, with nebulizer treatment administered en route when possible.

NREMT Respiratory Emergencies & Oxygen Delivery 2

A patient with asthma presents with wheezing, accessory muscle use, and a prolonged expiratory phase.
SpO2 is 91%.
Which position is MOST beneficial for this patient?