Respiratory arrest is a medical emergency where breathing stops completely or is so ineffective it cannot sustain life. It is distinct from cardiac arrest, which is the cessation of the heart’s pumping function. Although the heart may still be beating initially, the lack of oxygen delivery will quickly cause the heart to fail, leading to full cardiopulmonary arrest within minutes. Immediate intervention is necessary to prevent irreversible brain damage and death.
Recognizing the Signs of Arrest
Identifying respiratory arrest quickly is the first step in providing treatment. The most obvious sign is the absence of chest movement, indicating the person is not breathing, or the presence of gasping or labored breaths known as agonal breathing. Agonal breaths are often irregular, noisy, and insufficient to provide oxygen.
Lack of oxygen causes cyanosis, a noticeable blue or grey discoloration of the lips, nail beds, or skin. The person will rapidly become unresponsive as the brain is starved of oxygen. Once these signs are observed, especially unresponsiveness combined with absent or abnormal breathing, the emergency medical system (EMS) must be activated immediately by calling 911 or the local emergency number.
Immediate Layperson Response
While waiting for professional help, the bystander’s primary goal is to provide rescue breaths to deliver oxygen. The person’s airway must first be opened using the head-tilt, chin-lift maneuver. This involves placing one hand on the forehead and two fingers of the other hand under the chin, then gently tilting the head back and lifting the chin to move the tongue away from the back of the throat.
Once the airway is open, rescue breathing can be delivered using a barrier device or mouth-to-mouth technique. The rescuer should pinch the person’s nose shut, make a seal over their mouth, and deliver a breath lasting about one second, ensuring the chest visibly rises. Two initial rescue breaths are given, followed by one breath every six seconds for an adult, aiming for about ten breaths per minute.
If the person also shows signs of poor or absent circulation, such as not having a pulse, the intervention shifts to cardiopulmonary resuscitation (CPR). If a bystander is unsure about the pulse or if the person is unresponsive and not breathing normally, current guidelines advise initiating chest compressions at a rate of 100 to 120 per minute, in addition to rescue breaths. The combination of chest compressions and rescue breaths in a 30:2 cycle helps circulate oxygen until advanced care is available.
Advanced Medical Airway Support
Upon arrival, emergency medical services (EMS) personnel take over airway management using advanced techniques and equipment. Initial professional ventilation often involves a bag-valve mask (BVM) device, a self-inflating bag connected to a face mask that allows a trained provider to deliver high-concentration oxygen. Proper BVM ventilation requires a tight seal on the face and often a two-handed technique to maintain the head-tilt, chin-lift maneuver, ensuring adequate chest rise with each breath.
For prolonged transport or when BVM ventilation is insufficient, a more secure airway is established. Endotracheal intubation is the standard, involving the insertion of a specialized tube directly into the trachea, past the vocal cords. This tube is then connected to a mechanical ventilator, which controls the volume and rate of breaths delivered. Other advanced options include supraglottic devices, such as laryngeal mask airways, which sit above the vocal cords and are quicker to deploy.
Treating the Root Cause
Stabilizing the person with advanced airway support is only the first part of treatment; definitive care requires identifying and reversing the cause of the arrest. Respiratory arrest can stem from various conditions, including a severe asthma attack, a physical airway obstruction, or a central nervous system depressant like an opioid overdose. Once the person is being mechanically ventilated, a rapid assessment of the cause is initiated.
If the arrest is due to an opioid overdose, a reversal agent such as naloxone is administered to rapidly restore spontaneous breathing. For an airway obstruction, medical personnel will attempt to remove the foreign body using specialized tools like laryngoscopes or forceps. A severe asthma attack causing respiratory muscle fatigue is treated with high-dose bronchodilators and steroids to open the constricted airways.