II. Definitions

  1. Dyspnea
    1. Uncomfortable awareness of abnormal breathing
  2. Acute Dyspnea
    1. Subjective difficult or distressed breathing lasting <1 month

III. Causes

IV. Symptoms

  1. Shortness of Breath
  2. Chest tightness

V. Signs

  1. Patient breaks up sentence to pause for breath
  2. Tachypnea
  3. Increased respiratory excursions
  4. Nasal flaring
  5. Cyanosis
  6. Accessory Muscle use
    1. Chest and abdominal Muscle use
    2. Neck Muscle use (Scalene, Sternocleidomastoid)

VI. History

VII. Exam

  1. Airway Exam (includes nose and sinus exam)
    1. Stridor
    2. Drooling
    3. Trismus
    4. Peritonsillar Abscess
    5. Muffled voice
  2. Fluid status exam
    1. Jugular Venous Distention
    2. Hepatojugular Reflex
    3. Peripheral Edema
    4. Body weight (trend in recent weights)
  3. Peripheral Vascular Exam
    1. Decreased pulses or bruits
    2. Pulsus Paradoxus (>10 mm Hg Blood Pressure drop with inspiration)
  4. Respiratory Exam
    1. Increased AP Chest diameter
    2. Wheezing
    3. Rales
    4. Accessory Muscle use (Neck, chest, Abdomen)
    5. Speaking in phrases to catch breath
    6. Respiratory effort (Forced Vital Capacity or Peak Flow can be measured bedside)
  5. Cardiac Auscultation
    1. Tachycardia
    2. S3 Gallup Rhythm
    3. Cardiac Murmur
  6. Neurologic Exam
    1. Cranial Nerve deficit such as Ptosis, Diplopia, Dysarthria (Myasthenia Gravis)
    2. Symmetric leg weakness and Deep Tendon Reflex loss (Guillain Barre)
  7. Musculoskeletal Exam
    1. Severe kyphoscoliosis
    2. Pectus Excavatum
    3. Ankylosing Spondylitis
  8. Skin Exam
    1. Cyanosis or Pallor
    2. Digital Clubbing
  9. Psychomotor exam
    1. Anxiety

VIII. Labs (as directed by history and clinical findings)

  1. Hemoglobin or Hematocrit
  2. Thyroid Stimulating Hormone (TSH)
  3. Venous Blood Gas or Arterial Blood Gas
  4. Troponin
  5. D-Dimer (if Pulmonary Embolism risk)
  6. Lactic Acid (if Sepsis suspected)
  7. B-Type Natriuretic Peptide (BNP)
    1. BNP use expedites ER evaluation and lowers cost
      1. CHF most likely Dyspnea cause when BNP >500 pg/ml
      2. CHF unlikely Dyspnea cause when BNP <100 pg/ml
      3. Mueller (2004) N Engl J Med 350:647-54 [PubMed]
    2. BNP with Chest XRay identifies CHF as Dyspnea cause
      1. Knudson (2004) Am J Med 116:363-8 [PubMed]

IX. Diagnostics

  1. First-Line (most cases of undifferentiated Dyspnea)
    1. Electrocardiogram (EKG)
  2. Second line tests to consider (when stable)
    1. Pulmonary Function Tests (Spirometry)
    2. Exercise Treadmill Testing with Oxygen Saturation

X. Imaging

  1. Chest XRay
    1. Indicated in all cases
    2. Identifies primary pulmonary causes of Dyspnea
  2. Spiral CT or Ventilation-Perfusion Scan
    1. Indicated for Hypoxia with normal CXR, Spirometry
  3. Bedside Ultrasound
    1. See Lichtenstein Dyspnea Evaluation by Ultrasound Protocol (Blue Protocol)
    2. See Volpicelli Dyspnea Evaluation with Ultrasound Protocol
  4. Echocardiogram
    1. Indicated for suspected cardiogenic cause

XI. Evaluation: Phone Triage - Indications for Emergency Room Evaluation

  1. Adults
    1. Severe Dyspnea
    2. New onset of Dyspnea at rest
    3. Sudden Chest Pain onset associated with Dyspnea
  2. Children
    1. Dyspnea in a child under age 3 months
    2. Sudden onset Dyspnea
    3. Temperature over 102 F
    4. Lethargy
    5. Pharyngitis with Dyspnea
    6. Croup-type cough with Dyspnea
  3. References
    1. Zoorob (2003) Am Fam Physician 68(9):1803-10 [PubMed]

XII. Management: Acute Dyspnea

  1. Also see Chronic Dyspnea
  2. Immediate ABC Management
    1. Emergency Airway Management
    2. Emergency Breathing Management
    3. Emergency Circulation Management
  3. Obtain initial Vital Signs
    1. Temperature
    2. Blood Pressure
      1. Manage Hypotension
    3. Heart Rate
      1. Treat severe Symptomatic Bradycardia and Tachycardia via ACLS guidelines
    4. Respiratory Rate and Oxygen Saturation
  4. Immediately triage unstable patients
    1. Hypotension
    2. Altered Level of Consciousness
    3. Hypoxia (decreased Oxygen Saturation)
    4. Arrhythmia
    5. Stridor or other signs of upper airway obstruction
    6. Unilateral breath sounds or other Pneumothorax signs
    7. Respiratory Rate >40 breaths per minute
    8. Accessory Muscle use with retractions
    9. Cyanosis
  5. Initial management of acute distress
    1. Obtain Intravenous Access
    2. Administer High Flow Oxygen as indicated
      1. Oxygen is indicated for Hypoxia
      2. Do not be over-zealous with oxygen (it is not without risk, esp. in severe COPD with CO2 retention)
    3. Consider Non-Invasive Positive Pressure Ventilation (esp. BIPAP)
      1. Effective in many Dyspnea Causes (e.g. CHF, Obstructive Lung Disease, severe croup)
    4. Evaluate and treat Hypoxia if present
      1. Consider Pulmonary Embolism Diagnosis
    5. Suspected Acute Coronary Syndrome
      1. Aspirin 325 mg
      2. Nitroglycerin
  6. Initiate disease specific management
    1. See Emergency Management of Asthma Exacerbation
    2. See COPD Exacerbation Management
    3. See Acute Pulmonary Edema Management
    4. See Acute Coronary Syndrome
    5. See Pneumonia Management
    6. See Pulmonary Embolism Management
    7. See Tension Pneumothorax and Needle Thoracentesis
    8. See Cardiac Tamponade

XIII. References

  1. Braithwaite in Marx (2002) Rosen's Emergency, p. 155-62
  2. Degowin (1987) Diagnostic Exam, p. 281-2
  3. Fangman in Noble (2001) Primary Care, p. 175-8
  4. Marini (1987) Respiratory Medicine, p. 40-41
  5. Stulbarg in Murray (2000) Respiratory Med, p. 541-52
  6. Budhwar (2020) Am Fam Physician 101(9):542-8 [PubMed]
  7. Zoorob (2003) Am Fam Physician 68(9):1803-10 [PubMed]

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Related Studies

Ontology: Dyspnea (C0013404)

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
Korean 호흡곤란
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