CEN Respiratory Study Guide: Emergencies & Practice Questions

1. Assessment: is the patient working harder or beginning to tire?

Look at speech, alertness, respiratory rate and effort, chest movement, air entry, oxygen needs, and perfusion. Ask about onset, baseline lung disease, chest pain, fever, choking, and exposure. New drowsiness, exhaustion, weak effort, very poor air movement, or hypotension should raise concern for deterioration. Support airway and breathing and escalate promptly when the patient is failing. [3] [4]

CEN Thinking: SpO₂ describes oxygenation, not carbon dioxide clearance or the effort required to keep breathing. An acceptable saturation does not cancel concerning bedside findings.

On a phone, swipe sideways if needed. Sounds are clues, not diagnoses. [3] [4]

2. Asthma: a quieter chest needs a second look

Wheeze, cough, chest tightness, and prolonged expiration suggest airflow obstruction. Difficulty speaking, confusion, or a nearly silent chest with poor air entry indicates greater urgency. Early care addresses bronchospasm and oxygenation, with repeated assessment of the response. [5]

Key difference: Less wheeze with easier speech and better air entry suggests improvement. Less wheeze with drowsiness and weaker chest movement suggests the patient may be moving too little air to make noise.

3. COPD: compare with baseline without explaining away deterioration

Increased dyspnea, cough, or sputum change may indicate an exacerbation. Keep pneumonia, pneumothorax, PE, and cardiac disease in mind when the presentation is abrupt, unusual, or more severe than expected. Correct hypoxemia with appropriately titrated oxygen while assessing ventilation. [3] [4]

Exam trap: An improved saturation does not prove that ventilation improved. New drowsiness or weakening effort requires reassessment; a history of COPD is never a reason to ignore severe hypoxemia.

4. Obstruction, aspiration, croup, and inhalation injury

• Obstruction: Sudden choking with ineffective cough or inability to speak or breathe is an immediate airway emergency.
• Aspiration: Symptoms may start with choking, but lung injury and hypoxemia can evolve afterward. Initial improvement does not end reassessment.
• Croup: Barking cough and inspiratory stridor are characteristic. Stridor at rest, retractions, or fatigue increases concern. Keep the child calm; drooling or a toxic appearance should widen the differential. [7]
• Inhalation injury: Smoke exposure with hoarseness, soot, burns, or a changing voice suggests possible evolving airway injury. Seek early airway help; standard pulse oximetry can be misleading with carbon monoxide exposure. [4]

For these presentations, airway patency and the direction of change matter more than the label alone. [3] [4]

5. Pleural problems and chest trauma: air, fluid, or injury?

Pneumothorax may cause sudden pleuritic pain, dyspnea, and reduced unilateral breath sounds. Pleural effusion is fluid around the lung and may produce more gradual breathlessness. Following trauma, consider hemothorax, chest-wall injury, and pulmonary contusion as well. [3] [4]

What changes urgency: New hypotension, worsening oxygenation, or increasing effort. Shock with asymmetric breath sounds demands immediate team assessment. Reassess after the first examination because traumatic lung injury can become more apparent over time.

6. PE and pulmonary hypertension: breathing symptoms can signal circulatory trouble

Pulmonary embolism: Abrupt unexplained dyspnea, pleuritic pain, tachycardia, or syncope warrants consideration, especially with thromboembolic risk factors. Clear breath sounds do not exclude PE. Hypotension or deteriorating perfusion makes stabilization and urgent team involvement the priority. [3] [6]

Pulmonary hypertension: Compare with baseline, but treat new syncope, hypotension, or signs of right-heart failure as warning signs. Known chronic disease does not make a new decline routine. [8]

7. Infection, noncardiac pulmonary edema, and ARDS

Pneumonia may cause cough, fever, focal findings, and increased work of breathing; older or immunocompromised patients may present less typically. Assess oxygenation and perfusion, including signs of sepsis. [3] [4]

Rising oxygen needs and diffuse lung abnormalities after sepsis, aspiration, pneumonia, or trauma raise concern for noncardiac pulmonary edema or acute respiratory distress syndrome (ARDS). Distinguish this from edema driven primarily by left-heart failure. A satisfactory SpO₂ on progressively more oxygen is not evidence of recovery. [3]