From the Guidelines
The initial evaluation and management for a patient presenting with shortness of breath should begin with a rapid assessment of the patient's respiratory status, including vital signs and pulse oximetry, and supplemental oxygen should be administered immediately if oxygen saturation is below 94% or if the patient shows signs of respiratory distress, as recommended by the BTS guideline for oxygen use in adults in healthcare and emergency settings 1. The initial assessment should include recording of pulse rate, respiratory rate, and pulse oximetry, as suggested by the BTS guideline 1.
Key Components of Initial Evaluation
- A focused history to identify onset, duration, and severity of symptoms, as well as associated symptoms like chest pain, cough, or fever
- Physical examination to focus on respiratory effort, use of accessory muscles, lung sounds, cardiac examination, and signs of potential causes like fluid overload or allergic reaction
- Initial diagnostic tests, including pulse oximetry, electrocardiogram, chest X-ray, and basic laboratory tests, such as complete blood count, basic metabolic panel, and cardiac enzymes if cardiac etiology is suspected
Oxygen Therapy
- For acutely breathless patients not at risk of hypercapnic respiratory failure who have saturations below 85%, treatment should be started with a reservoir mask at 15 L/min, as recommended by the BTS guideline 1
- The oxygen concentration can be adjusted downwards to maintain a target saturation of 94-98% once the patient has stabilized
Treatment
- Treatment should target the underlying cause, which may include:
- Bronchodilators (albuterol 2.5mg via nebulizer or 4-8 puffs via MDI) for bronchospasm
- Diuretics (furosemide 40mg IV) for heart failure
- Antibiotics for pneumonia
- Anticoagulation for pulmonary embolism
Monitoring and Escalation
- Continuous monitoring of vital signs and response to therapy is essential
- Escalation to non-invasive ventilation (CPAP or BiPAP) or intubation if respiratory failure develops, as needed.
From the Research
Initial Evaluation of Shortness of Breath
The initial evaluation of a patient presenting with shortness of breath involves a thorough history and physical examination to determine the underlying cause of the symptom.
- The patient's history should include questions about the onset and duration of the shortness of breath, as well as any associated symptoms such as chest pain or cough 2.
- A physical examination of the chest should be conducted, including inspection, palpation, percussion, and auscultation, to assess for any abnormalities in the lungs or chest wall 3.
Management of Shortness of Breath
The management of shortness of breath depends on the underlying cause of the symptom.
- For patients with chronic obstructive pulmonary disease (COPD), treatment may include corticosteroids, antibiotics, and bronchodilators, as well as oxygen supplementation and ventilatory support if necessary 4.
- For patients with acute dyspnea, a thorough history and clinical examination can help determine the most likely causes of the symptom, and guide rational testing and treatment decisions 5.
- The pathophysiology of dyspnoea is complex, and involves the activation of several pathways that lead to increased work of breathing, stimulation of the receptors of the upper or lower airway, lung parenchyma, or chest wall, and excessive stimulation of the respiratory centre by central and peripheral chemoreceptors 6.