Respiratory Emergencies

Patients present to the emergency department with various respiratory complaints. Their signs and
symptoms range from mild to life threatening. As an emergency nurse, you must recognize early warning
signs of respiratory compromise and intervene before further respiratory deterioration occurs.

This lesson discusses the basic anatomy and physiology of the respiratory system as well as respiratory
emergencies that commonly occur in adults, including:

 Acute bronchitis
 Pneumonia
 Asthma
 Chronic obstructive pulmonary disease, including chronic bronchitis and emphysema
 Pulmonary embolus
 Pulmonary edema
 Spontaneous pneumothorax
 Foreign body aspiration
Respiratory Emergencies
Anatomy and Physiology Review: Respiratory Structures
The respiratory system can be divided into two parts: the upper airway and the lower airway.

The upper airway includes the:

 Nasopharynx
 Oropharynx
 Laryngopharynx
 Larynx
 The larynx connects the upper and lower airways and acts as a gate to prevent aspiration.
The lower airway includes the:
  Trachea
 Bronchi
 Bronchioles
 Alveoli
 The alveolus, the functional unit of the respiratory system, interacts with adjacent capillaries
to ensure oxygen transport from the alveolus into the blood.1 Alveoli remain open because of
surfactant, a detergent-like substance that reduces surface tension in the alveoli.
C-shaped cartilaginous rings support upper airways to prevent collapse. In the lower airways,
cartilaginous rings gradually disappear as airway structures branch and are replaced by smooth muscles
in the bronchioles.

Anatomy and Physiology Review: Inspiration and Expiration

As a result of negative intrathoracic pressure in the pleural cavity, air is pulled into the lungs during
inspiration. With inspiration, air is filtered, warmed, and humidified as it travels through the upper and
lower airways.1 During expiration, the negative pressure decreases, and air is passively expelled.
Cilia (hairlike structures in the passageways) help move air toward the alveoli. Cilia also help move
mucus and debris out of the pulmonary system, keeping the lower airways from being contaminated.

Mucus-secreting goblet cells help maintain the sterility of the lower airway. Mucus traps debris and keeps
the airway moist.

Gas exchange occurs in the alveoli and pulmonary capillaries. Oxygen and carbon dioxide are exchanged
at this cellular level.

Respiratory Emergencies
Anatomy and Physiology Review: Cellular Oxygenation
Cellular oxygenation depends on:

 An adequate supply of oxygen delivered to cells

 The affinity of hemoglobin for oxygen
  The ease with which hemoglobin releases oxygen to cells
The oxygen-hemoglobin dissociation curve describes hemoglobin's affinity for oxygen. Oxygen dissociation is affected by
carbon dioxide pressure (PCO2) level.
 If the curve shifts to the left, hemoglobin picks up oxygen more easily in the lungs but does not easily release oxyg
 When the curve shifts to the right, the oxygen uptake by hemoglobin is less rapid, but oxygen delivery to the cells is

Respiratory Emergencies
Anatomy and Physiology Review: Ventilation, Respiration and Perfusion
Normal gas exchange depends on adequate ventilation and perfusion.

Ventilation refers to the mechanical flow of air into and out of the lungs (inspiration and expiration).
Respiration is the exchange of oxygen and carbon dioxide at the cellular level. It is divided into four
distinct processes:
 Pulmonary ventilation
 Diffusion of oxygen and carbon dioxide across the alveolar-capillary membrane
 Transport of oxygen and carbon dioxide to and from the cells
 Regulation of ventilation
Perfusion relates to the transport of blood to the tissues. A ventilation-perfusion (V/Q) mismatch occurs
when ventilation or perfusion is inadequate. When an extreme imbalance occurs, inadequately
oxygenated blood is shunted into the arterial system.

Assessment

Evaluating the respiratory system is an important part of assessing and maintaining airway, breathing,
and circulation (ABCs). Be prepared to identify and intervene for conditions that may lead to:

 Hypoxia (inadequate tissue oxygenation)

 Hyperventilation (too-rapid ventilation that decreases carbon dioxide tension)
 Hypoventilation (reduced air entry into the alveoli, which decreases the oxygen level and increases
the carbon dioxide level in the blood)

Hypoxia:
 Inadequate oxygen tension at the cellular level, characterized by
tachycardia, hypertension, peripheral vasoconstriction, dizziness, and
mental confusion. Mild hypoxia stimulates peripheral chemoreceptors to
increase heart and respiratory rates. In severe hypoxia, the central
mechanisms that regulate breathing fail, leading to irregular respiration,
Cheyne-Stokes respiration, apnea, and respiratory and cardiac failure.
Increased sensitivity to the depressant effect of opiates on the
respiratory system is common in chronic hypoxia, causing the severe
depression of respiration or apnea from relatively small doses. If the
availability of oxygen is inadequate for aerobic cellular metabolism,
energy is provided by less efficient anaerobic pathways that produce
metabolites other than carbon dioxide and water. The tissues most
sensitive to hypoxia are the brain, heart, pulmonary vessels, and liver.
Treatment may include cardiotonic and respiratory stimulant drugs,
oxygen therapy, mechanical ventilation, and frequent analysis of blood
gases.
Hyperventilation:
An increased respiratory rate, an increased tidal volume, or both, which
results in a pulmonary ventilation rate greater than that metabolically
necessary for gas exchange. Hyperventilation causes an excessive
intake of oxygen and elimination of carbon dioxide and may cause
hyperoxygenation. Hypocapnia and respiratory alkalosis then occur,
leading to dizziness, faintness, numbness of the fingers and toes,
possible syncope, and psychomotor impairment.

The causes of hyperventilation include:

 Asthma or early emphysema

 Increased metabolic rate caused by exercise, fever,
hyperthyroidism, or infection
 Lesions of the central nervous system, as in cerebral thrombosis,
encephalitis, head injuries, or meningitis
 Hypoxia or metabolic acidosis
 The use of hormones and drugs, such as epinephrine,
progesterone, and salicylates
 Difficulties with mechanical respirators
 Psychogenic factors, such as acute anxiety or pain.
 Hypoventilation:
 An abnormal condition of the respiratory system that occurs when the
volume of air that enters the alveoli and takes part in gas exchange is
 inadequate for the body's metabolic needs. It is characterized by
cyanosis, polycythemia, increased PaCO2, and a generalized decreased
respiratory function. Hypoventilation may be caused by an uneven
distribution of inspired air (as in bronchitis), obesity, neuromuscular or
skeletal disease affecting the thorax, the decreased response of the
respiratory center to carbon dioxide, or a reduced amount of functional
lung tissue, as in atelectasis, emphysema, and pleural effusion. The
results of hypoventilation are hypoxia, hypercapnia, pulmonary
hypertension with cor pulmonale, and respiratory acidosis. Treatment
includes weight reduction in cases of obesity, artificial respiration, and
possible tracheostomy.
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 

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During the assessment, be sure to obtain a patient history, which should include:

 Past medical history

 Time of onset of signs and symptoms
 What occurred just before the event
 History of similar episodes
 Smoking history
  Orthopnea
 Nocturnal dyspnea
 Exposure to occupational hazards associated with specific lung diseases, such as:
 Asbestos, which is linked to asbestosis
 Beryllium dust, which is related to berylliosis
 Bird droppings, which are associated with bird handler's lung
 Coal dust, which causes black lung
 Iron oxide, which can result in siderosis
 Silica dust, which is linked to silicosis

 Smoking decreases lung compliance by damaging the elastin and collagen fibers. Smokers
usually have a decreased sense of taste and smell along with increased secretions and cough.
Cigarette smoke negatively affects functions in the pulmonary system that normally keep it clear.
Smoking increases the likelihood of lung cancer, chronic bronchitis, emphysema, and respiratory
infection.
 Orthopnea:
 An abnormal condition in which a person must sit or stand to breathe
deeply or comfortably. It occurs in many disorders of the cardiac and
respiratory systems, such as asthma, pulmonary edema, emphysema,
pneumonia, congestive heart failure, and angina pectoris. Assessment
includes noting the number of pillows used by the patient. Patients with
orthopnea also report sleeping in recliners.
Respiratory Emergencies
Assessment: Breath Sounds

Media Credit
After assessing airway patency and breathing effectiveness, listen for adventitious breath sounds and
obtain a full set of vital signs.

Auscultate the lung sounds to identify normal—and abnormal—sounds. To review normal breath sounds,
click on the links below:3
 Bronchial sounds
 Bronchovesicular sounds
 Vesicular sounds
To review various abnormal breath sounds, click on the links below:3
 Bronchial sounds, abnormal locations
 Fine crackles
 Medium crackles
 Coarse crackles
 Sonorous wheezes (rhonchi)
 Sibilant wheezes
 Stridor
 Physical characteristics, such as a barrel chest and club fingers, are often associated with chronic
obstructive pulmonary disease. These findings can be normal in some patients but can also
indicate cardiovascular abnormalities, such as valvular heart disease and congenital defect.
Assessment: Monitoring and Testing
For a patient who presents with a respiratory complaint, expect to perform these common interventions:

 Monitor oxygen saturation, cardiac rhythm, capnography, and vital signs.

 Administer oxygen, as indicated.
 Obtain a chest radiograph.
 Draw blood for a complete blood count.
 Obtain a blood sample for arterial or venous blood gas levels.
This table presents normal arterial and venous blood gas values. 4
Arterial Blood Venous Blood
Parameter
Gas Values Gas Values
pH 7.35 to 7.45 7.32 to 7.43
Partial pressure of carbon 35 to 45 mm Hg 40 to 45 mm Hg
dioxide (PaCO2)
Bicarbonate (HCO3-) 22 to 26 mEq/L 22 to 26 mEq/L
(mmol/L) (mmol/L)
Partial pressure of alveolar 80 to 100 mm Hg 38 to 42 mm Hg
oxygen (PaO2+)*
Oxygen saturation 96% to 100% 60% to 80%
Base excess ± 2.0 mEq/L ± 2.0 mEq/L
* This pressure decreases above sea level and with increasing age.
Source: Adapted from Lewis, S.L., Dirksen, S.R., Heitkemper, M.M.,
Bucher, L., & Camera, I.M. (2011). Medical-surgical nursing: Assessment
and management of clinical problems (8th ed.). St. Louis: Mosby Elsevier.

Acute Bronchitis: Manifestations

Patients with acute bronchitis report these signs and symptoms:

 Sore throat
 Stuffy nose
 Cough
 Initially, the cough is dry and nonproductive and may worsen at night. After a few days, the
cough usually becomes productive.
 Wheezes, heard on auscultation, that usually clear with coughing
 Other manifestations, such as low-grade fever, chest discomfort, and fatigue
The diagnosis is based on the clinical presentation. Chest radiography distinguishes between acute
bronchitis and pneumonia.

Acute Bronchitis: Treatment

Media Credit
As ordered, provide treatments:

 Administer cough suppressants and expectorants.

 Administer an inhaled bronchodilator, if needed, for wheezing and bronchospasm.
Encourage the patient to:

 Increase their fluid intake.

 Avoid smoke and other irritants.
 Use a vaporizer to add moisture to the air.
Do not give antibiotics except to treat secondary bacterial infections. 5
Respiratory Emergencies: Pneumonia

Pneumonia is an inflammatory reaction that usually results from an acute bacterial, viral, or fungal
infection. It may follow an upper respiratory, ear, or eye infection.
 Left-sided pneumonia
Media Credit
When pneumonia is suspected, diagnostic tests may include:

 Chest radiography
 Sputum culture and sensitivity testing and Gram staining
 Laboratory tests, including a complete blood count
 Pulse oximetry, which is obtained initially and then monitored to detect changes in oxygenation
 Arterial blood gas levels, which may be obtained as a baseline
For a patient with pneumonia, provide treatment as ordered. As indicated, anticipate these interventions:

 Administer humidified oxygen, as needed, to maintain oxygenation.

 Administer antibiotics for the presumed bacterial infection.
 Monitor the patient's fluid and electrolyte balance and provide replacements, as indicated.
 Before the first antibiotic dose, draw a blood sample for culture and sensitivity testing for any patient
admitted with community-acquired pneumonia.
 Do not delay antibiotic administration for the results of blood culture and sensitivity testing.
 Stress the importance of pneumococcal vaccination and flu shots. If the patient smokes, provide
information about smoking cessation.

Asthma is a reversible obstructive lung disease characterized by airway inflammation and hyperreactivity
in response to certain triggers. In this disease, the alveoli become distended but are not destroyed.

Clinical manifestations of asthma can include:

 Cough
 Wheezes
 Prolonged expiratory time
 Reduced peak expiratory flow
 Increased work of breathing
 Accessory muscle use
 Decreased level of consciousness
 Decreased air movement
 Low oxygen saturation
Respiratory Emergencies
Asthma: Treatment
In the emergency department, the short-term goal of asthma management is to reverse airflow
obstruction. The goals of long-term asthma management are to:12
 Maintain near-normal pulmonary function and exercise levels
 Prevent chronic symptoms and acute exacerbations
 Avoid adverse effects of medications
To help achieve these goals, intervene as ordered:

Click here for the latest evidence regarding asthma.

The peak expiratory flow rate is the greatest flow velocity produced during forced expiration after fully
expanding the lungs during inspiration. This test:

 Provides objective data for asthma management

 Documents the patient's personal best and daily variations
 Detects impending exacerbations
 Guides medication therapy
 Helps identify triggers
To correctly obtain peak expiratory flow measurements, have the patient stand (if possible), take a deep
breath, and forcefully blow out all inspired air into the flow meter. Record the highest of three readings.

To promote asthma management, teach the patient to keep a diary of peak expiratory flow measurements
along with documentation of viral infections, weather, medication changes, environments, and other
possible triggers

Respiratory Emergencies
Asthma: Common Pulmonary Medications

Media Credit
Medications that help manage asthma and other respiratory disorders work by:

 Reducing bronchial spasms

 Reducing airway inflammation
 Minimizing mucosal edema and airway hyperreactivity
These medications can be given orally, intravenously, or subcutaneously or may be inhaled. The forms of
inhaled therapy include nebulization and direct inhalation of aeresols or powders. Inhalation therapy
offers several benefits, including:

 The use of smaller medication doses

 A faster onset of action
 The direct delivery of the medication to the respiratory system
 Fewer adverse effects
 Painless, convenient administration
 Asthma: Common Pulmonary Medications (Continued)

 The slides below summarize the common medications that are used to treat asthma.
Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible syndrome characterized by
a diminished inspiratory and expiratory capacity of the lungs. This category of respiratory disease
includes emphysema and chronic bronchitis.

In most patients, chronic obstructive pulmonary disease is associated with a history of active and passive
smoking. Although a direct correlation exists between smoking and chronic bronchitis or emphysema, not
all smokers develop these diseases. Smoking cessation may prevent the development or progression of
chronic obstructive pulmonary disease.
Respiratory Emergencies
Chronic Obstructive Pulmonary Disease: Chronic Bronchitis
Chronic bronchitis is a chronic obstructive pulmonary disease of the larger airways. The
inflammation of the bronchial mucous membranes causes increased mucus production. This
inflammation directly results from irritants such as cigarette smoke, fumes, and dust. The
increased mucus production leads to swelling and the enlargement of the submucosal glands and
may lead to airway obstruction.

Chronic
Obstructive Pulmonary Disease: Emphysema

Click the images to enlarge

Emphysema is a chronic obstructive pulmonary disease characterized by:

 The permanent abnormal enlargement of the respiratory tract distal to the terminal bronchioles
 Destructive changes of the alveolar wall
The breakdown of the alveolar walls markedly reduces the pulmonary capillary bed, which is essential for
oxygen and carbon dioxide exchange between the alveolar air and capillary blood. The loss of elastic
tissue in the lungs leads to narrowed bronchioles. Increased pressure around the outside of the airway
lumen leads to increased airway resistance and decreased airflow. This destroys the elastic properties of
the lungs and causes a loss of natural recoil and support.17
Initially, patients may exhibit signs of chronic bronchitis. Dyspnea on exertion occurs first and progresses
to dyspnea at rest. Increasing dyspnea indicates increasing airway obstruction. In advanced stages, the
patient may exhibit:

 Increased anteroposterior diameter of the chest

 Dorsal kyphosis
 Elevated ribs
 Flare at the costal margin
 Widening of the costal angle, as in barrel chest
 Diminished breath sounds with expiratory wheezes
 Hyperresonance (due to lung hyperinflation), usually in all lung fields
Chronic Obstructive Pulmonary Disease: Management

Media Credit
In the emergency department, the management of emphysema and chronic bronchitis is the same. For
either type of chronic obstructive pulmonary disease, expect to provide treatment that includes:

 Oxygen therapy
 Administer low-flow oxygen with a nasal cannula or Venturi mask. Do not withhold high-flow
oxygen when the patient is in respiratory failure.18
 Nebulized medications
 Bronchodilators
 Corticosteroids
 Antibiotics (if a bacterial infection is present)
Respiratory Emergencies: Pulmonary Embolus

A pulmonary embolus is an undissolved piece of material that occludes a pulmonary vessel and obstructs
the distal circulation. About 10 percent of patients with a fatal pulmonary embolus die within 1 hour after
the onset of signs and symptoms.19
Most pulmonary thromboemboli originate in the deep veins of the legs. Virchow's triad—blood stasis,
damage to vessel wall epithelium, and coagulation alterations—can lead to the formation of venous
thrombi. An embolus becomes dislodged and travels through the venous system and the right side of the
heart. It finally lodges in a pulmonary vessel, obstructing blood flow and decreasing perfusion to part of
the lungs.

Risk factors for developing a pulmonary embolus include:19

 Immobility
 Trauma
 Surgery
 Long bone fractures
 Pregnancy
 Cancer
  Heart failure
 Use of estrogen, as in oral contraceptives
 Obesity
 Thrombophlebitis

The signs and symptoms of a possible pulmonary embolus include:

 Dyspnea, which is the most common symptom

 Tachycardia and tachypnea
 Restlessness, apprehension, anxiety, or all three
 Shortness of breath or bronchospasm, which may occur suddenly
 Chest pain, which can be severe and may worsen on inspiration
 Diaphoresis
 Crackles on auscultation
 Cough and hemoptysis
 Fever
 Syncope
 Petechiae, especially on the chest (usually related to fat emboli)
 Hypotension and right ventricular failure (related to large vessel occlusion)
Pulmonary Embolus: Diagnosis

Pulmonary embolism is commonly underdiagnosed because the clinical presentation is often nonspecific.

Prepare the patient for diagnostic tests, such as:

 Spiral computed tomography of the chest (the primary diagnostic test in many emergency
departments)
 Ventilation-perfusion scan
 Pulmonary angiography
 This test is the gold standard for diagnosing pulmonary emboli. Although it is the most
accurate, it poses the greatest risk.
 Chest radiography, which may be normal
 Electrocardiography, which may show nonspecific changes
 Laboratory tests, including D-dimer, to rule out other possible causes of the symptoms
 Duplex ultrasonography of both legs to assess for deep vein thrombosis
In a 2012 prospective cohort study, a Wells score of less than or equal to 4 combined with a negative
qualitative D-dimer test was shown to exclude pulmonary embolism in primary care
patients.20 Click here to view a table listing the variables of the modified Wells prediction rule for
diagnosing pulmonary embolism.
Maintain the patient's airway, breathing, and circulation.

As ordered, perform these interventions:

 Perform continuous cardiac monitoring.

 Administer supplemental oxygen therapy.
 Administer analgesics.
 Infuse intravenous fluids.
 Administer vasopressors, if needed, to maintain blood pressure.
 Give anticoagulants after the diagnosis has been made.
 If the patient will be admitted, give a bolus of weight-based heparin and start a continuous
infusion. Give a low-molecular-weight heparin, if it is used in your facility.
 If the patient will have outpatient therapy, administer low-molecular-weight heparin and teach
self-administration for continued home care.
 Provide fibrinolytic therapy, which is an option for unstable patients.
 Medications may include urokinase (Abbokinase) or a tissue plasminogen activator, such
as alteplase (Activase).
 Prepare the patient for an embolectomy.
 Prepare the patient for inferior vena cava filter placement.
 Respiratory Emergencies: Pulmonary Edema

 Pulmonary edema is a life-threatening complication of an acute event. The two types of
pulmonary edema are cardiogenic and noncardiogenic.
Respiratory Emergencies
Pulmonary Edema: Signs and Symptoms

Media Credit
The signs and symptoms of pulmonary edema include severe dyspnea, diaphoresis, hypertension,
tachycardia, tachypnea, anxiety, and possibly pink, frothy sputum. The patient may display these and
other cardiovascular and respiratory findings.21
Cardiovascular signs and symptoms result from a fluid overload. Poor left ventricular function generally
precedes poor right ventricular function, which leads to:

 Heart failure with distended jugular veins

 Sacral edema when the patient is sitting with the legs not in a dependent position
 Pitting edema in the lower extremities
 Weight gain
 Rapid, bounding pulse, which becomes weak and thready if untreated
 S3 and S4 heart sounds
 Cool, pale, moist skin that may appear cyanotic or mottled
 Increased blood pressure initially in an attempt to pump the excess fluid
 Decreased blood pressure as the condition worsens
Respiratory Emergencies
Pulmonary Edema: Signs and Symptoms (Continued)
Respiratory signs and symptoms occur when increased alveolar fluid impairs oxygen exchange across
the alveolar-capillary membrane. The patient develops:

 Dyspnea and an increased respiratory rate in an effort to increase oxygenation

 This increased respiratory rate decreases the partial pressure of carbon dioxide, causing
respiratory alkalosis.
As the condition worsens:

 Respiratory acidosis occurs when the lungs cannot remove all of the carbon dioxide the body
produces.
 The respiratory effort is labored as the patient tires from the breathing effort.
 Fluid in the lungs causes crackles and a productive cough with frothy, white sputum.
 Sputum may be pink tinged in fulminant pulmonary edema.
 Cyanosis and decreased oxygen saturation may occur as hypoxia increases.
 Bronchospasms may develop, causing wheezes.
 Chest radiography usually shows bilateral interstitial and alveolar infiltrates.
 The left ventricle usually enlarges, giving the heart a water-bottle shape.
Respiratory Emergencies
Pulmonary Edema: Treatment

Media Credit
Focus your interventions on improving oxygenation, improving cardiac function, and decreasing cardiac
workload. As ordered, perform these interventions:

 Administer high-flow oxygen.

 Administer inhaled bronchodilators.
 Place the patient in the high-Fowler's position.
 Provide positive end-expiratory pressure when hypoxia continues despite aggressive oxygen
therapy.
 Anticipate the use of continuous positive airway pressure (CPAP) or intubation.
 Administer medications, as prescribed:
 Diuretics, such as furosemide (Lasix) and bumetanide (Bumex), decrease cardiac workload
by decreasing preload.
 Nitroglycerin (Nitro-Bid) increases venous distention and venous pooling and decreases blood
return to the heart, which reduces preload. It can be given sublingually or intravenously.
 Dobutamine (Dobutrex) increases cardiac contractility and reduces peripheral vascular
resistance.
 Dopamine (Intropin) increases the heart rate and causes vasoconstriction in an effort to
increase blood pressure. It is usually used for hemodynamically significant hypotension.
 Nitroprusside (Nitropress) decreases afterload.
 Phosphodiesterase inhibitors, such as milrinone (Primacor), increase contractility and cause
vasodilation.
Respiratory Emergencies
Respiratory Emergencies: Spontaneous Pneumothorax
Spontaneous pneumothorax may occur with or without an underlying pulmonary disorder and usually
results from the rupture of an apical, subpleural emphysematous bleb. Pneumothorax may be primary,
secondary, or iatrogenic:

 Primary spontaneous pneumothorax occurs in individuals who do not have a known pulmonary
disease.
 Secondary spontaneous pneumothorax occurs in patients with a history of a pulmonary disorder
such as chronic obstructive pulmonary disease or pulmonary fibrosis.
 Iatrogenic pneumothorax can result from an invasive procedure (such as subclavian catheter
insertion or transthoracic needle aspiration) or from trauma due to mechanical ventilation or
cardiopulmonary resuscitation.
Foreign body aspiration usually occurs in pediatric and geriatric patients. An aspirated solid or semisolid
object may lodge in the larynx or trachea. The objects most likely to be aspirated include:

 Food, especially seeds and nuts

 Bone fragments
 Nails
 Pins
 Small toys
 Coins, especially with pediatric patients
 Medical instrument fragments
 Dental appliances
Among adults, the reasons for aspiration include:

 Impaired swallow reflex

 Impaired cough reflex
 Intellectual disability
 Alcohol or sedative use
 General anesthesia
 Poor dentition
 Dental, pharyngeal, or airway procedures
 Altered sensorium
 Loss of consciousness
 Seizures
 Maxillofacial trauma
Respiratory Emergencies
Foreign Body Aspiration: Manifestations and Treatment

Media Credit
When a foreign body is aspirated into the upper airway, the patient presents with obvious signs and
symptoms. The condition may be immediately life threatening.

When a foreign body is aspirated into the lower airways, the presentation can vary. Usually, the patient
has a new onset of sudden coughing, gagging, and choking. Unless the airway is completely obstructed,
the patient may be asymptomatic for a time.

The treatment depends on the severity of the aspiration. If a foreign body occludes the upper airway, take
these steps:

1. Follow basic life support measures to try to clear the airway.

2. If basic life support measures are unsuccessful, directly visualize the area with a laryngoscope and
try to clear the airway.
3. If all attempts fail to clear the airway, perform or assist with a needle or surgical cricothyrotomy.
 Expect to use chest or neck radiography to reveal the foreign body.
 Anticipate foreign body removal via direct visualization.
Lower airway obstruction usually requires a bronchoscopy to relieve the airway obstruction. 2