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Respiratory calls are among the most frequent and most challenging incidents paramedics and EMTs face. These challenges can range from mild symptoms to life-threatening conditions.
The complexity comes not only from the patient’s distress but from how many body systems and treatment variables are involved. Managing these patients in the field requires quick thinking, clinical reasoning, and a deep understanding of how the lungs, heart, and brain interact.
There are two things that are an absolute must to be successful assessing patients with respiratory complaints.
First, know and completely understand the difference between respiratory distress and respiratory failure.
Second, recognizing whether the patient is exhibiting inspiratory or expiratory shortness of breath.
This information is readily available within the first 30 seconds of patient contact and can make the difference between success and failure, treatment first steps and transport decisions.
A lack of understanding of these key elements will often lead to patient/treatment desynchrony.1 Some key problems encountered when assessing respiratory patients:
Difficulty in assessing severity: Respiratory distress even failure can vary greatly in severity, from mild wheezing to complete uncompensated respiratory failure. Paramedics must quickly determine how serious the situation is and prioritize interventions and resources appropriately.
Airway management: Ensuring the airway is open and unobstructed is critical. Some patients may have swelling, secretions, or foreign objects blocking the airway, which can be challenging to manage, especially in the back of a moving ambulance.
Limited access to advanced diagnostic tools: EMS in most cases lack the sophisticated diagnostic tools (like blood gas analysis or advanced imaging) that a hospital would have. This makes it more difficult to get a precise diagnosis for underlying conditions, such as pneumonia, pulmonary embolism, or chronic obstructive pulmonary disease (COPD).
Varying patient conditions: Respiratory problems can arise from a variety of causes such as asthma, COPD, pneumonia, pulmonary embolism, or cardiac issues which require different treatments. It can be difficult to differentiate between these conditions while treating them improperly may worsen the patient’s condition. Respiratory patients are complicated because breathing involves multiple interconnected systems the lungs, heart, brain, and circulatory system and even small changes in one can throw off the others.
Oxygenation and ventilation issues: Managing oxygen delivery and ventilation can be difficult in patients with severe respiratory problems. Some may require supplemental oxygen, nebulized medications, advanced airway devices, non-invasive ventilation or even a ventilator.
Anxiety and panic: Respiratory distress often causes patients to panic, which can exacerbate the problem by increasing their oxygen demand and worsening the difficulty in breathing or shortness of breath. Calming the patient while simultaneously providing treatment is a delicate balance.
Environmental conditions: Treating respiratory issues in challenging environments can further complicate treatment and transport.
Coexisting medical conditions: Many patients with respiratory issues also have underlying medical problems like heart disease, diabetes, or kidney failure, which can complicate treatment and decision-making.
Transport to appropriate care facilities: Depending on the severity, some patients may need to be transported to specialized care centers and coordinating the appropriate level of care during transport is essential.
Patient Factors Add Challenges
Every patient presents differently. COPD and asthma patients may have chronic air trapping that makes ventilation difficult. Obese or trauma patients have positioning issues that reduce chest expansion. Elderly patients often take multiple medications and have limited physiological reserves. Anxiety or fatigue can make them uncooperative or unable to follow directions.
So, how quickly can a medic or most healthcare providers differentiate between respiratory distress and respiratory failure? The astute clinician should be able to tell the difference in under 30 seconds
Respiratory Distress: The Body Is Still Fighting
Respiratory distress means the patient is having difficulty breathing, but the body is still able to compensate and maintain adequate oxygenation and carbon dioxide levels at least for the time being.2
In distress, the patient’s respiratory system is working harder to move air in and out, using every tool available including, increased respiratory rate, accessory muscle use and positioning to maintain gas exchange.
Respiratory distress patients are alert even though their work of breathing is increased. They are maintaining their blood gase levels (O2 and CO2) at or near normal values. The bottom line is the body is working hard but still winning the fight. The question is how long can they continue to do the work?
Respiratory Failure: The Body Is Losing the Fight. Gas Exchange Is Failing
Respiratory failure means the patient can no longer maintain adequate oxygenation or ventilation, even with maximal effort. The compensatory mechanisms have failed and without intervention oxygen levels drop, CO₂ rises, and tissue hypoxia sets in.
This leads to fatigue, altered mental status, respiratory arrest and ultimately cardiac arrest. If the patient appears to be falling asleep (most likely due to CO2 narcosis) the patient has gone from respiratory distress to respiratory failure.
After determining if a patient is in respiratory distress or respiratory failure the next assessment determinate is which direction are they have trouble breathing, getting the air in or getting the air out. Patients with expiratory shortness of breath have difficulty exhaling and will exhibit a long expiratory phase most often caused by narrowing of the airway.
Narrowing the airway by 50% can increase the work of breathing 15 fold. Patients with expiratory shortness of breath most often have an underlying problem with asthma or COPD and may require a nebulizer treatment along with other medications.
Patients with inspiratory shortness of breath are having trouble getting the air in. The expiratory phase is often normal with an obvious increase in the work to inhale. This is often seen in congestive heart failure (CHF) or pulmonary edema.
These patients rarely require a nebulizer treatment unless they have a combination problem exhibiting both inspiratory and expiratory shortness of breath.
Breathing Sounds vs. Breath Sounds
The terms “breath sounds” and “breathing sounds” are often used interchangeably (causing confusion), however they are different.
There can be whole courses taught on breath and breathing sounds complicating the assessment of respiratory patient. Not to mention the noisy environment often found pre-hospital.
Breath Sounds
- Breath sounds refer to the noises produced by airflow through the respiratory system, especially as heard through a stethoscope during a physical assessment.
- These sounds can be normal (like vesicular breath sounds heard in healthy lungs) or abnormal (like crackles, wheezes, or rhonchi, which may indicate respiratory conditions).
- The focus is usually on sounds produced while air moves into and out of the lungs and airways.
Breathing Sounds
- This term is often used more broadly to describe any noises associated with the process of breathing, including sounds made by the body during both inhalation and exhalation.
- It can encompass things like normal breathing patterns, snoring, labored breathing, or abnormal breathing noises caused by obstruction or other conditions.
In short, breath sounds often refer to specific sounds heard during an assessment, while breathing sounds can refer more generally to any sounds or patterns made during the act of breathing.
Patients in respiratory failure regardless of the cause will often require mechanical ventilation. Patients in respiratory distress are good candidates for BiLevel (CPAP) non-invasive ventilation therapy.3
The use of single level CPAP will most likely increase work of breathing due to the increase in expiratory resistance.
Every step from positioning and suctioning to bag-valve-mask (BVM) use, CPAP/BiPAP, or intubation requires skill and precision. Respiratory emergencies require balancing oxygenation, ventilation, perfusion, and patient comfort all while working with limited time and tools.
Unlike a hospital, the field offers no ABGs, X-rays, or lab results. Paramedics must rely on assessment skills, experience, and limited tools to make decisions.
Knowing when to escalate from oxygen to CPAP to BVM or intubation and when to transport rapidly is the difference between stabilization and decline.
Takeaway Message
- Distress = Compensating. Support the effort oxygen, bronchodilators, CPAP, and close monitoring.
- Failure = Decompensating. Take over the work of breathing BVM, intubation, or ventilatory support.
- Always watch for the transition point when a patient moves from distress to failure. That’s your cue to act fast.
Summary
It’s been reported that respiratory patients make up over 40% of all EMS responses. The initial assessment by first arriving EMS providers can and often does make a difference in the final outcome.
Having the courage to take on the most challenging patients in some of the more challenging environments is what makes EMS great.
References
1. Tonelli, R., Protti, A., Spinelli, E. et al. Assessing inspiratory drive and effort in critically ill patients at the bedside. Crit Care 29, 339 (2025). https://doi.org/10.1186/s13054-025-05526-0
2. Castro Villamor MA, Alonso-Sanz M, López-Izquierdo R, et al. Comparison of eight prehospital early warning scores in life-threatening acute respiratory distress: a prospective, observational, multicentre, ambulance-based, external validation study. Lancet Digit Health. 2024 Mar;6(3):e166–e175.
3. Winniford C. Undifferentiated Respiratory Distress: A Medic’s Guide (Part 2). EMS Airway. Published June 6, 2025. Accessed February 5, 2026. https://emsairway.com/2025/06/06/undifferentiated-respiratory-distress-a-medics-guide-part-2/
Capt. Steven LeCroy (Ret.) MA, CRT, EMTP, spent more than 30 years with St. Petersburg (FL) Fire & Rescue and retired as a captain paramedic. In addition, he was an adjunct instructor at St. Petersburg College for 35 years and has been certified as a respiratory therapist since 1978. He has been retained as an EMS expert in over 130 cases. He currently works for a medical device company as their director of Clinical Support.
