Early management of out-of-hospital respiratory distress: an interdisciplinary consensus guidance

Background: Respiratory distress represents one of the most prevalent clinical presentations in out-of-hospital emergency medicine. Despite its frequency, optimal out-of-hospital management remains variable, and evidence-based guidance is lacking. Methods: An interdisciplinary panel of sixteen experts employed the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method to evaluate 56 statements on the assessment and treatment of out-of-hospital respiratory distress. These statements were developed through a scoping review of the literature and expert clinical judgment. Appropriateness ratings were performed over two rounds. Non-voting observers from patient associations participated in the discussions to represent the patient perspective. Results: The scoping review identified the available evidence on out-of- hospital respiratory distress and informed the development of 56 candidate statements subsequently evaluated by the panel. After the two-round RAND/UCLA consensus process, 27 statements (49%) were rated as appropriate, 13 (23%) as uncertain, and 16 (29%) as inappropriate. Oxygen therapy was rated appropriate both to improve symptoms (median 8, interquartile range (IQR) 8–9; disagreement index (DI) −0.20) and to prevent clinical deterioration (median 8, IQR 7.75–9; DI −0.20). Non- invasive ventilation received similarly high appropriateness ratings for improving symptoms (median 8, IQR 8–9; DI −0.34) and preventing deterioration (median 8.5, IQR 8–9; DI −0.34). The panel agreed on the need for early treatment, with oxygen therapy initiated within 10 minutes judged appropriate (median 8, IQR 8–9; DI −0.34). Advanced respiratory support was preferred over oxygen alone in moderate-to-severe respiratory distress (median 8, IQR 8–8.25; DI 0.00). Conclusions: This consensus provides practical, expert-driven recommendations to standardize early management of out-of-hospital respiratory distress. While many recommendations reached strong agreement, areas of uncertainty remain, underscoring the need for further clinical research.