What is the approach to evaluating dyspnea (shortness of breath) in an urgent care setting?

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Last updated: May 28, 2025View editorial policy

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From the Guidelines

Evaluating shortness of breath in urgent care should start with a rapid 'ABC' assessment, followed by obtaining a quick history and measuring vital signs, including pulse rate, respiratory rate, and pulse oximetry, as recommended by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. When evaluating shortness of breath, it is essential to consider the patient's overall appearance and determine the severity of their condition.

  • The initial assessment should include:
    • Measuring pulse and respiratory rate in all cases
    • Pulse oximetry to assess for hypoxaemia
    • Recording disease-specific measurements, such as peak expiratory flow in asthma or blood pressure in cardiac disease
  • A brief history should be taken from the patient or other informant to identify potential causes of shortness of breath, including onset, duration, associated symptoms, and relevant medical history.
  • The physical examination should include lung auscultation, cardiac exam, and assessment for peripheral edema, jugular venous distention, or accessory muscle use. According to the BTS guideline 1, pulse oximetry should always be measured in patients with breathlessness or suspected hypoxaemia, and disease-specific measurements should also be recorded. The goal of this approach is to quickly identify the underlying cause of shortness of breath and provide appropriate treatment, while also determining the need for hospitalization or safe discharge with follow-up.

From the Research

Evaluation of Shortness of Breath

To evaluate shortness of breath in urgent care, the following steps can be taken:

  • Identify the underlying cause of shortness of breath, which can be challenging due to the various potential causes 2
  • Use an evidence-based approach to determine the etiology of shortness of breath, considering factors such as the patient's medical history, physical examination, and laboratory results 3
  • Consider the patient's symptoms, such as dyspnea, cough, and sputum production, and assess their severity 4

Assessment and Management

The assessment and management of shortness of breath may involve:

  • Targeted oxygen therapy, titrated to an SpO2 of 88-92% 4
  • Arterial blood gases to assess gas exchange in patients with COPD exacerbation 4
  • Inhaled short-acting bronchodilators, which can be provided by nebulizer, pressurized metered-dose inhaler, or dry powder inhaler 4
  • Noninvasive ventilation (NIV) for patients with COPD exacerbation, as supported by clinical practice guidelines 4

Patient Characteristics and Improvement

Patient characteristics, such as baseline breathlessness and body mass index (BMI), may be associated with improvement in breathlessness after treatment with morphine 5

  • Worse baseline breathlessness and higher BMI may be associated with a clinically meaningful improvement in breathlessness in patients using morphine 5
  • Understanding the pathophysiology of common diseases contributing to dyspnea can guide rational testing and informed treatment decisions 6

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Pitfalls in the evaluation of shortness of breath.

Emergency medicine clinics of North America, 2010

Research

Evaluation of the patient with shortness of breath: an evidence based approach.

Emergency medicine clinics of North America, 1999

Research

Approach to Adult Patients with Acute Dyspnea.

Emergency medicine clinics of North America, 2016

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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