II. Definitions
- Dyspnea
- Uncomfortable awareness of abnormal breathing
- Acute Dyspnea
- Subjective difficult or distressed breathing lasting <1 month
III. Causes
- See Dyspnea Causes
IV. Symptoms
- Shortness of Breath
- Chest tightness
V. Signs
VI. History
- See Dyspnea History
VII. Exam
- Airway Exam (includes nose and sinus exam)
- Stridor
- Drooling
- Trismus
- Peritonsillar Abscess
- Muffled voice
- Fluid status exam
- Jugular Venous Distention
- Hepatojugular Reflex
- Peripheral Edema
- Body weight (trend in recent weights)
- Peripheral Vascular Exam
- Decreased pulses or bruits
- Pulsus Paradoxus (>10 mm Hg Blood Pressure drop with inspiration)
- Respiratory Exam
- Cardiac Auscultation
- Tachycardia
- S3 Gallup Rhythm
- Cardiac Murmur
-
Neurologic Exam
- Cranial Nerve deficit such as Ptosis, Diplopia, Dysarthria (Myasthenia Gravis)
- Symmetric leg weakness and Deep Tendon Reflex loss (Guillain Barre)
-
Musculoskeletal Exam
- Severe kyphoscoliosis
- Pectus Excavatum
- Ankylosing Spondylitis
- Skin Exam
- Cyanosis or Pallor
- Digital Clubbing
- Psychomotor exam
- Anxiety
VIII. Labs (as directed by history and clinical findings)
- Hemoglobin or Hematocrit
- Thyroid Stimulating Hormone (TSH)
- Venous Blood Gas or Arterial Blood Gas
- Troponin
- D-Dimer (if Pulmonary Embolism risk)
- Lactic Acid (if Sepsis suspected)
-
B-Type Natriuretic Peptide (BNP)
- BNP use expedites ER evaluation and lowers cost
- CHF most likely Dyspnea cause when BNP >500 pg/ml
- CHF unlikely Dyspnea cause when BNP <100 pg/ml
- Mueller (2004) N Engl J Med 350:647-54 [PubMed]
- BNP with Chest XRay identifies CHF as Dyspnea cause
- BNP use expedites ER evaluation and lowers cost
IX. Diagnostics
- First-Line (most cases of undifferentiated Dyspnea)
- Electrocardiogram (EKG)
- Second line tests to consider (when stable)
X. Imaging
-
Chest XRay
- Indicated in all cases
- Identifies primary pulmonary causes of Dyspnea
- Spiral CT or Ventilation-Perfusion Scan
- Indicated for Hypoxia with normal CXR, Spirometry
- Bedside Ultrasound
-
Echocardiogram
- Indicated for suspected cardiogenic cause
XI. Evaluation: Phone Triage - Indications for Emergency Room Evaluation
- Adults
- Severe Dyspnea
- New onset of Dyspnea at rest
- Sudden Chest Pain onset associated with Dyspnea
- Children
- Dyspnea in a child under age 3 months
- Sudden onset Dyspnea
- Temperature over 102 F
- Lethargy
- Pharyngitis with Dyspnea
- Croup-type cough with Dyspnea
- References
XII. Management: Acute Dyspnea
- Also see Chronic Dyspnea
- Immediate ABC Management
- Obtain initial Vital Signs
- Temperature
- Blood Pressure
- Manage Hypotension
- Heart Rate
- Treat severe Symptomatic Bradycardia and Tachycardia via ACLS guidelines
- Respiratory Rate and Oxygen Saturation
- Immediately triage Unstable Patients
- Hypotension
- Altered Level of Consciousness
- Hypoxia (decreased Oxygen Saturation)
- Arrhythmia
- Stridor or other signs of upper airway obstruction
- Unilateral breath sounds or other Pneumothorax signs
- Respiratory Rate >40 breaths per minute
- Accessory Muscle use with retractions
- Cyanosis
- Initial management of acute distress
- Obtain Intravenous Access
- Administer High Flow Oxygen as indicated
- Consider Non-Invasive Positive Pressure Ventilation (esp. BIPAP)
- Effective in many Dyspnea Causes (e.g. CHF, Obstructive Lung Disease, severe croup)
- Evaluate and treat Hypoxia if present
- Consider Pulmonary Embolism Diagnosis
- Suspected Acute Coronary Syndrome
- Aspirin 325 mg
- Nitroglycerin
- Initiate disease specific management
XIII. References
- Braithwaite in Marx (2002) Rosen's Emergency, p. 155-62
- Degowin (1987) Diagnostic Exam, p. 281-2
- Fangman in Noble (2001) Primary Care, p. 175-8
- Marini (1987) Respiratory Medicine, p. 40-41
- Stulbarg in Murray (2000) Respiratory Med, p. 541-52
- Budhwar (2020) Am Fam Physician 101(9):542-8 [PubMed]
- Zoorob (2003) Am Fam Physician 68(9):1803-10 [PubMed]
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Related Studies
Definition (NCI) | An uncomfortable sensation of difficulty breathing. It may present as an acute or chronic sign of an underlying respiratory or heart disorder. |
Definition (NCI_CTCAE) | A disorder characterized by an uncomfortable sensation of difficulty breathing. |
Definition (NCI_NCI-GLOSS) | Difficult, painful breathing or shortness of breath. |
Definition (MSH) | Difficult or labored breathing. |
Definition (PSY) | Difficulty in breathing which may or may not have an organic cause. |
Definition (CSP) | labored or difficult breathing associated with a variety of disorders, indicating inadequate ventilation or low blood oxygen or a subjective experience of breathing discomfort. |
Concepts | Sign or Symptom (T184) |
MSH | D004417 |
ICD9 | 786.05 |
ICD10 | R06.0 , R06.02, R06.00 |
SnomedCT | 308149007, 207059009, 207057006, 139192008, 158371003, 139200001, 49233005, 139201002, 161945003, 139207003, 161937008, 161946002, 161951008, 158379001, 207062007, 267036007, 230145002 |
LNC | LP115812-2, MTHU038266, MTHU020850, LA17001-1 |
English | Dyspneas, BREATH SHORTNESS, BREATHING DIFFICULT, DYSPNOEA, SOB, Breathlessness NOS, Dyspnea, [D]Breathlessness (context-dependent category), [D]Dyspnea (context-dependent category), [D]Shortness of breath (context-dependent category), Dyspnea NOS, [D]Dyspnea, [D]Dyspnoea, [D]Shortness of breath, [D]Breathlessness, shortness of breath, dyspnea, difficulty breathing, SOB (shortness of breath), difficulty breathing (symptom), shortness of breath (symptom), Short of breath, Breath shortness, Breathing difficult, Dyspnoea NOS, Dyspnoeas, Dyspnea [Disease/Finding], Breath Shortness, Shortness of Breath, Breath Shortnesses, Shortness (of);breath, Difficulty;breathing, breathing difficulties, breathing difficulty, breathless, difficult breathing, breathing shortness, respiratory difficulty, breath shortness, shortness of breath (SOB), Dyspnea, unspecified, Respiratory difficulties, (Symptom: [SOB] or [breathlessness] or [dyspnea]) or (breathlessness), [D]Breathlessness (situation), [D]Shortness of breath (situation), Dyspnoea (finding), Short of breath symptom, Dyspnoea - symptom, Shortness of breath symptom, Breathlessness symptom, Breathlessness NOS (finding), [D]Dyspnoea (situation), (Symptom: [SOB] or [breathlessness] or [dyspnoea]) or (breathlessness), (Symptom: [SOB] or [breathlessness] or [dyspnoea]) or (breathlessness) (finding), Dyspnea - symptom, [D]Dyspnea (situation), BREATHING DIFFICULTIES, DYSPNEA, DIFFICULTY BREATHING, Breathlessness, Breathlessnesses, Shortness of breath, Difficulty breathing, Respiration difficult, Dyspnoea, DIB - Difficulty in breathing, SOB - Shortness of breath, Breathless, Difficulty breathing (finding), Dyspnea (finding), Shortness of breath/dyspnoea, breath; shortness of breath, breathlessness, shortness of breath; breath, Dyspnea, NOS, Dyspnoea, NOS, Difficulty breathing [Ambiguous], Dyspnea (finding) [Ambiguous], tightness of breath, dyspnoea |
French | DYSPNEE, Difficultés à respirer, Difficulté respiratoire, Essoufflement, Essouf, Respiration difficile, Dyspnée SAI, Essouflé(e), DIFFICULTE RESPIRATOIRE, SOUFFLE COURT, Dyspnées, Dyspnée |
Portuguese | DISPNEIA, Dispneia NE, Dispneico, Falta de ar, Dificuldade em respirar, Dificuldade da respiração, DIFICULDADE RESPIRATORIA, RESPIRACAO DE BAIXA AMPLITUDE, Dispneia, Falta de Ar, Dispneias |
Spanish | DISNEA, Respiración dificil, DR, DR (dificultad respiratoria), Disnea NEOM, Respiración difícil, Dificultad al respirar, Dificultad para respirar, Falta de aliento, Dificultad de la respiración, [D]falta de aire (categoría dependiente del contexto), [D]respiración agitada (categoría dependiente del contexto), RESPIRACION ACORTADA, RESPIRACION, DIFICULTAD, falta de aliento, SAI (hallazgo), falta de aliento, SAI, [D]respiración agitada, [D]disnea (situación), [D]respiración agitada (situación), respiración dificultosa, [D]falta de aliento, [D]falta de aire (situación), [D]disnea, dificultad respiratoria, Breathlessness NOS, [D]falta de aire, falta de aire, [D]disnea (categoría dependiente del contexto), [D]falta de aliento (categoría dependiente del contexto), dificultad para respirar (hallazgo), dificultad para respirar, disnea (concepto no activo), disnea (hallazgo), disnea, respiración difícil (hallazgo), respiración difícil, Disneas, Disnea |
German | DYSPNOE, Atemlosigkeit, Schwierigkeiten beim Atmen, SOB, Kurzatmigkeit, Atmung erschwert, kurzatmig, SOB (Kurzatmigkeit), Dyspnoe NNB, ATMUNG ERSCHWERT, KURZATMIGKEIT, Dyspnoen, Atemnot, Dyspnoe |
Italian | Dispnee, Respirazione difficoltosa, Dispnea NAS, Difficoltà nella respirazione, Dispnea e anomalie respiratorie, Dispnea |
Dutch | moeilijk ademen, kortademigheid, kortademigheid NAO, dyspnoea, Kortademigheid, adem; kortademigheid, kortademigheid; adem, Ademnood, Dyspneu, Dyspnoe, Dyspnoea |
Japanese | 呼吸困難NOS, イキギレ, コキュウコンナン, コキュウコンナンNOS, 呼吸窮迫, 呼吸困難, 息切れ |
Swedish | Andnöd |
Czech | dyspnoe, dušnost, Pocit dechové nedostatečnosti, Dušnosti, Dyspnoe, Dušnost, Ztížené dýchání, Pocit zkráceného dechu, Dýchání ztížené, Dyspnoe NOS, Dýchavičnost |
Finnish | Hengenahdistus |
Russian | ODYSHKA, ОДЫШКА |
Korean | 호흡곤란 |
Croatian | DISPNEJA |
Polish | Duszność |
Hungarian | Légszomj, Fulladás, Nehézlégzés, Légszomj (fulladás), Kilégzési rövidség, Légzésrövidülés, Nehézlégzések, Légzés nehezített, Dyspnoe k.m.n., Nehéz légzés |
Norwegian | Andpustenhet, Dyspné, Åndenød, Tungpustethet, Tung pust |
Ontology: Orthopnea (C0085619)
Concepts | Sign or Symptom (T184) |
ICD9 | 786.02 |
ICD10 | R06.01 |
SnomedCT | 207051007, 62744007, 158373000, 161942000, 139197002 |
English | Breathless - lying flat, Must sit up to breath, [D]Orthopnea (context-dependent category), [D]Orthopnea, [D]Orthopnoea, Orthopnea, breath sit up, orthopnea, [D]Orthopnoea (situation), (Breathless - lying flat) or (orthopnoea symptom), (Breathless - lying flat) or (orthopnea symptom), Orthopnea symptom, (Breathless - lying flat) or (orthopnoea symptom) (finding), [D]Orthopnea (situation), Orthopnoea symptom, Orthopnoea, Breathlessness lying flat, Orthopnea (finding), orthopnoea |
Italian | Ortopnea |
Japanese | 起坐呼吸, キザコキュウ |
Spanish | [D]ortopnea (categoría dependiente del contexto), [D]ortopnea (situación), [D]ortopnea, ortopnea (hallazgo), ortopnea, Ortopnea |
Czech | Ortopnoe |
Hungarian | Orthopnoe |
Portuguese | Ortopneia |
Dutch | orthopnoea |
French | Orthopnée |
German | Orthopnoe |
Ontology: Acute dyspnea (C0743323)
Concepts | Sign or Symptom (T184) |
English | Acute dyspnea, Acute dyspnoea, dyspnea acute, acute dyspnea |
Dutch | acute dyspneu |
French | Dyspnée aiguë |
German | akute Atemnot, akute Dyspnoe |
Italian | Dispnea acuta |
Portuguese | Dispneia aguda |
Spanish | Disnea aguda |
Japanese | 急性呼吸困難, キュウセイコキュウコンナン |
Czech | Akutní dyspnoe |
Hungarian | Acut dyspnoe |