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Acute Dyspnea

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Acute Dyspnea, Dyspnea, Shortness of Breath, Orthopnea

  • Definition
  • Acute Dyspnea
  1. Subjective difficult or distressed breathing <1 month
  • Causes
  • Symptoms
  1. Shortness of Breath
  2. Chest tightness
  • 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)
  • History
  • 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
  3. Peripheral Vascular Exam
    1. Decreased pulses or bruits
  4. Respiratory Exam
    1. Increased AP Chest diameter
    2. Wheezing
    3. Rales
    4. Cyanosis
    5. Clubbing
    6. Accessory muscle use (Neck, chest, Abdomen)
    7. Speaking in phrases to catch breath
    8. 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. Psychomotor exam
    1. Anxiety
  7. Neurologic Exam
    1. Cranial Nerve deficit such as Ptosis, Diplopia, Dysarthria (Myasthenia Gravis)
    2. Symmetric leg weakness and Deep Tendon Reflex loss (Guillain Barre)
  • 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]
  • 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
  • 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
  • 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]
  • 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
  • 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. Zoorob (2003) Am Fam Physician 68(9):1803-10 [PubMed]