How to Manage a Respiratory Arrest

Respiratory arrest is a critical situation that can lead to significant and irreversible brain and other organ damage and even death. The swift action of both non-medical bystanders and medical professionals can significantly influence the outcome for this patient. It can give them a chance at a full recovery they are not likely to have otherwise.

CPR and First aid courses provide the average person with the knowledge and confidence they need to make rational decisions during an emotionally-charged event like a respiratory failure. Additionally, ACLS algorithms provide you with scientifically proven and internationally recognized best practices for managing Advanced Cardiac Life Support as a medical professional. 

Below, you’ll explore how to identify respiratory arrest and how you can act competently and confidently to save a life during these challenging situations.

What is a Respiratory Arrest?

A respiratory arrest is a medical event where the ability of a person to breathe stops. It is also called “respiratory failure”. According to MerckManuals.com, without intervention, within around 5 minutes, organs, including the brain, will experience irreversible damage.

Intervention may include first aid and bystander CPR, then Advanced Cardiac Life Support (ACLS) once emergency personnel arrives.

Respiratory arrest is one of the most common causes of cardiac arrest, stopping the heart. Although, cause and effect can happen in the opposite direction as well.

When a person stops breathing, a series of events happen in their body.

1. Carbon dioxide builds up in the blood
2. Carbonic acid lowers the body’s pH, making the body acidic.
3. Excessive acidity damages the brain and organs.
4. Oxygen depletes, making it impossible for organs to function correctly.
5. Organs like the heart and brain stop working.
6. Organ tissues start to die, which may not be reversible.
7. Death occurs without intervention

Cardiac Arrest Vs. Respiratory Arrest

Respiratory or pulmonary arrest involves the lungs, while cardiac arrest involves the heart. However, respiratory arrest and cardiac arrest are closely linked.  When they happen together, they’re often just called “cardiac arrest” for simplicity.

This can lead to some confusion over terminology. With that said, both can benefit from CPR and ACLS, so in an emergency, no one should be arguing semantics.

Respiratory Arrest Vs. Respiratory Distress

Respiratory distress happens when someone has trouble breathing, but breathing hasn’t stopped. They’re usually still conscious and trying to breathe.  Some examples of this might be:

• Asthma attack
• Severe allergic reaction
• Blockage / Choking
• Being stuck in an airtight space like a junk refrigerator or object like a plastic bag (events more likely to happen with children)
• Someone intentionally constricting the breathing of another person
• Neurologic and lung diseases

Respiratory distress and respiratory arrest are also different in how they’re managed. If someone is experiencing respiratory distress, then you’d need to identify the cause of the distress and take appropriate first aid treatment actions for the reason. But if someone is in respiratory arrest, they need CPR usually followed by ACLS performed by medical professionals.

However, note that respiratory distress can become respiratory arrest if the correct first aid isn’t administered. Depending on the cause, an appropriate first aid treatment for respiratory distress might be:

• Rescue inhaler
• Epi-pen
• Encouraging the person to cough
• Heimlich maneuver
• Getting fresh air
• Removing the person from the allergen 
• ACLS algorithm treatments like establishing an airway and intubation 

People experiencing breathing distress will eventually experience hypoxia, a condition where a person can breathe but can’t get enough oxygen. The brain has to prioritize where the oxygen goes to help the person get out of the situation. But the brain can only do this for so long. eventually, organs will start to shut down, including one’s you can’t live without even for a short time, like the heart and brain.

What Causes Respiratory Arrest?

According to Medscape, some common causes include:

• Breathing distress
• Cardiac arrest 
• COPD
• Pneumonia
• Severe asthma attack
• Pulmonary arterial hypertension
• Embolism – a blockage caused by an embolus/clot
• Poisoning
• Muscle disorder
• Infection, such as tetanus or COVID-19

Some other common culprits include:

• Agonal breathing –  A particular type of sporadic breathing that a patient may experience after the heart stops
• Severe sleep apnea – Apnea, by definition, is when you stop breathing. But usually, it’s brief, and you gasp to catch your breath. In some cases, however, if you’re asleep or impaired by substances, you may not gasp and go into respiratory arrest.
• Opioid overdose – Heroin, Oxy, Fentanyl, and other opiates/opioids impact the brain system, which is responsible for managing your life support functions like breathing and heart rate. Too much can stop breathing, altogether. Other drug classes and substances can have a similar effect.
• Ischemic Stroke  – Generally, a clot or clogged artery blocks blood oxygen from the brain, and the patient’s vital organs start to shut down
• Hemorrhagic Stroke – Bleeding arteries can’t effectively transport oxygen, and the lungs shut down
• Anoxia – This is a catch-all term for anything that completely depletes oxygen, such as drowning or suffocation
• Among others

Signs of Respiratory Failure Vs. Respiratory Distress

To manage respiratory arrest effectively, it’s crucial to be able to identify its pre-cursor, respiratory distress. How can you tell if someone is having trouble breathing? Look for these signs of respiratory distress:

• Flared nostrils
• Increased respiratory effort
• Doesn’t appear to be trying to breathe (common with overdose)
• Odd airway sounds
• Pale, cool skin
• Extending and retracting the abdomen to assist breathing
• Loss of consciousness
• Agitation
• Racing pulse

Distress becomes arrest when no air is moving or complete apnea/arrest occurs. It’s often accompanied by these signs of respiratory arrest:

• Racing heart
• Abnormally slow heartbeat
• Confusion
• Loss of consciousness

Types of Respiratory Arrest

Upper Airway

This would be a nasal blockage and/or throat/epiglottis blockage. A nasal blockage that causes pulmonary arrest is most common in infants who do not yet realize they can breathe through their mouth if the nose is blocked. Additionally, at any age, a sudden loss of tongue muscle control or blockage in the throat can occur.

Blood, mucous, vomit, or an object could also get lodged there. Or tracheal spasms and inflammation could also close off the airways.

Lower Airway

Lower airway obstructions include bronchospasms or fluid build-up, such as pneumonia, edema, or hemorrhage, in addition to drowning.

Decreased Effort

Decreased effort happens when the brain stops sending signals to breathe. It’s most common with overdose, adverse drug reaction, or a metabolic issue. Metabolism involves the changing of resources into energy within the mitochondria inside cells. If the body loses its ability to produce or use energy, it can’t send the correct signals to organs and they stop doing their jobs.

Muscle Weakness / Paralysis

This typically involves neuromuscular disorders. But it can also happen due to extreme fatigue from forced over-breathing. This may happen during managed ventilation in a medical setting. Medically-trained rescuers must apply the appropriate levels of breathing support treatment to prevent this.

These are discussed in-depth in ACLS training.

How to Manage a Respiratory Event

Now that you’ve established the many causes and types of respiratory failure, it’s time to look at how medical professionals manage a patient event by following an ACLS algorithm. But first, let’s briefly look at the process that a bystander rescuer can follow using CPR and first aid to support breathing while emergency help arrives.

What Should the Bystander Rescuer Do?

When a person who is not medically trained provides first aid or CPR, we often call them a “bystander” or “rescuer”. However, it is much more likely that the person you help will be a family or friend.

A small study published by the National Institutes of Health (Nih.gov) found that you may be nearly twice as likely to witness a family/friend having a Cardiac-respiratory event compared to that of a stranger. But you’re also half as likely to initiate CPR compared to a stranger.

This is an unfortunate statistic, given that strong evidence shows that the initiation of CPR by a bystander is strongly linked to a better outcome for the patient. So what should you do?

First, do consider learning how to properly administer CPR and first aid during a respiratory event. You’ll find a free online First Aid and CPR course here.

In summary, 

• Assess the cause of breathing distress and address that cause by applying first aid for respiratory distress. 
• If the person is already in respiratory arrest, call 911 or yell for someone to call 911.
• Get out the AED ( automatic external defibrillator), which will be available in most public places and businesses. AED’s are “automatic”, so they do most of the work. You learn how to use one in an online CPR course. 
• Follow the steps to provide CPR using the CPR algorithm, which is a visual flow chart of steps to perform high-quality CPR.
• Continue CPR until professional help arrives or the person becomes conscious again.

How to Manage a Respiratory Event Using ACLS

If you are a medical professional with access to medical equipment, you have the access and expertise to follow ACLS algorithms within your scope of practice. When performing ACLS, you’re likely working with a team of rescuers.

There are several ACLS algorithms you should familiarize yourself with. For example, if you have a suspected stroke, you’ll use the Adult Suspected Stroke Algorithm. If the patient has tachycardia (a dangerously racing heart), you’ll use the Adult Tachycardia Algorithm, and so on.

In summary, during a respiratory arrest, you’ll take the following steps which are discussed in more detail in an online ACLS course

Assess the Situation

Try to identify the possible cause of the respiratory failure so you can take the best course of action. If you have pocket algorithms or an algorithms app, you should pull that up if you have time. 

• Yell for help if you’re alone or call 911.
• Start CPR / Provide Basic Life Support.
• Begin CPR and have someone continue CPR while the other does the following.

Note: If you’re an alone rescuer, you’ll need to weigh whether you should pause CPR to take the below steps. If the person’s chest is rising, they are breathing, so you should continue CPR.

Manage the Airway

Monitor and manage the airway. This may involve bag ventilation or something more advanced like:

• Laryngeal mask airway
• Laryngeal tube
• Esophageal-tracheal tube
• Endotracheal tube

You’ll need to assess the best breathing treatment within your scope of practice.

Suctioning may be required to maintain the airway. If there is a lot of blood, vomit, or other fluid, you should suction it immediately. But these attempts should not exceed 10 seconds. You don’t want them to interfere with high-quality CPR.

Monitor Patient Breathing Vitals

During a cardiac arrest, you should administer 100% oxygen and monitor the O2 Sat. Work to keep it above 94%.

If available, use quantitative waveform capnography to assess the amount of CO2 building up in the blood. You’re looking for a normal partial pressure of CO2 of 35 to 40 mmHg.

High-quality CPR should be able to achieve both of these measures.

Manage Circulation

Attach monitors to measure blood pressure and heart rhythm. Insert and IV if possible for the administration of medications and fluids stated in the ACLS algorithms. These will vary depending on the cause.

Shock a Shockable Rhythm

If using an AED, wait for a shockable rhythm and shock according to guidelines.

Diagnose

Further, assess the cause and work to reverse it as possible while continuing CPR. 

Apply Occam’s Razor here. “The simplest explanation is usually the right one”. Only stop CPR briefly if needed to diagnose and treat the cause.

ACLS training goes into great detail on how to manage various diagnoses and apply the appropriate treatment, so you should additionally review complete ACLS algorithms for managing respiratory failure before applying any of these advanced instructions.

If you witness a cardio-respiratory event like these, it’s important to be ready to work with others to apply scientifically proven first aid, CPR, and ACLS procedures. Training in these skills gives both everyday individuals and medical professionals the confidence they need to work with others or solo to save a life. Have you witnessed cardio-respiratory event? Share your story with us.