If a patient is in respiratory distress, go through your initial actions (bring help, ABC’s IV, oxygen) and then focus on the respiratory system. Your first major decision is whether the patient needs immediate intubation or not. Some factors in that decision are:
• Is the patient newly obtunded? If so, intubate
• Can the patient speak? If they can only say 1-2 words without taking a breath, you should prepare for intubation. If there is a quick fix (reactive airway disease and an albuterol treatment) or if theyre sats are maintaining over 92%, you have some time, but you must remain with the patient until things improve
• Are they using accessory muscles, grunting, sweating, and looking tired? Check ABG and CXR stat, and prepare for intubation
Remember if a patient has a fixable problem that requires a procedure (hemothorax, penumothorax, etc.) but exhibit the signs written above, the patient could crash if you give them any sedation. It may be safer to intubate the patient, perform the procedure, transfer to ICU, and re-assess over several hours.

Let’s say you’ve decided not to intubate them, you want to re-examine their lungs, get an ABG, and a CXR. If their CXR looks OK and their ABG shows a poor PO2 and a middling pCO2 you must rule out PE. PE will not always make someone short of breath, it can present in a myriad of ways.

So the algorithm is, if someone is in respiratory distress:
• Do they need to be intubated? – yes, no, maybe.
• Do they or do they not have a mechanical problem within their chest that’s keeping them from ventilating? – Listen to lungs, get stat CXR
• Next, think of the wide variety of things that cause respiratory issues (aspiration, worsening pneumonia, fluid overload from excess input or inadequate urine output, fluid overload caused by an M.I., or most importantly in surgical patients – Pulmonary embolism
o You are not going to be able to rule in or out PE at the bedside (examining their calves usually is of no help). You need to have a high index of suspicion. That index is affected by: are they getting proper DVT prophylaxis, do they have a long bone or pelvic fracture, is this their first time out of bed in 5 days, etc.
We’ll have more on PE in a separate post.