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Managing Adult Medical Emergencies in the Dental Office

Course Number: 516

Ventilation Failure

Ventilation failure (Table 8) is defined as a rise in CO2 concentration when alveolar ventilation either falls or fails to respond adequately to increased CO2 production. The most common causes are acute exacerbation of asthma and COPD. Asthma is diffuse airway inflammation caused by household (dust mites, pets) and environmental (pollens) allergens in genetically susceptible patients resulting in reversible bronchoconstriction. COPD (chronic bronchitis, emphysema) is a reversible airway obstruction caused an inflammatory response to toxins, e.g., cigarette smoke.

Table 8. Ventilation Failure.

  • Identify at-risk patient
    • Reduce stress
    • Do not prescribe or administer respiratory depressants and COX-inhibitors
    • Ensure profound local anesthesia
      • Use local anesthetic agents containing a vasoconstrictor congruent with the patient’s functional capacity
Signs and symptoms:
  • Coughing, wheezing, shortness of breath (dyspnea)
  • Anxiety, restlessness, agitation
  • Pallor or cyanosis of the lips
  • Noticeable use of the accessory muscles of respiration
  • Patient may become confused and lethargic
  • Respiratory failure (in cases of severe exacerbation)
Emergency response:
  • Place patient in an upright position
    • Administer a short acting beta2 agonist bronchodilator
      • Two to 4 puffs of albuterol by metered-dose inhaler (up to 3 times 20 minutes apart)
    • Administer oxygen
      • Patients with asthma do not need O2 unless the O2sat is <90% as measured by a pulse oximeter
        • 2 to 4 L/minute by nasal cannula
      • Patients with COPD require O2 supplementation, even those who do not need it chronically
        • 2 L/minute by nasal cannula (higher levels of O2 may worsen respiratory failure)
  • If patient’s condition deteriorates
    • Notify EMS
      • Monitor vital signs
        • If at any time the patient becomes unresponsive, no normal breathing, and no palpable pulse consider the diagnosis of cardiac arrest
          • Immediate CPR and defibrillation congruent with current recommendations
Nota bene:
  • Signs of recovery: the rate and character of breathing returns to normal
  • Signs of deterioration: no improvement in the rate and character of breathing, increased cyanosis
  • When ventilating a patient, squeeze the bag only until resistance is felt or the chest starts to rise and allow time for expiration
    • Attempting to ventilate with large volumes of air or too rapidly will increase “air-trapping” and may lead to pneumothorax
  • Patients with a particularly severe ongoing asthma attack (status asthmaticus) who do not respond to usual treatment may progress to acute respiratory arrest and death