What is the initial management of shortness of breath in the emergency room (ER)?

From the Guidelines

The initial management of shortness of breath in the emergency room should start with supplemental oxygen therapy, aiming for an oxygen saturation target range of 94-98% (or 88-92% in patients with COPD or other risk factors for hypercapnic respiratory failure), using a nasal cannula at 2-6 L/min or a simple face mask at 5-10 L/min, unless the patient has a saturation below 85%, in which case a reservoir mask at 15 L/min is recommended 1.

When managing shortness of breath in the ER, it's crucial to follow a systematic approach, starting with the ABCs (airway, breathing, circulation) assessment. The patient should be positioned upright to optimize respiratory mechanics. Establishing IV access and placing the patient on continuous cardiac and oxygen saturation monitoring are also essential steps.

Key considerations include:

• Providing supplemental oxygen as described above, based on the patient's oxygen saturation level and underlying conditions such as COPD 1.
• Obtaining vital signs, including respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation.
• Ordering immediate diagnostic tests, such as chest X-ray, ECG, complete blood count, basic metabolic panel, cardiac enzymes, and arterial blood gas if severe distress is present.
• Administering medications based on the suspected cause, such as albuterol for bronchospasm, furosemide for heart failure, aspirin for suspected cardiac ischemia, or antibiotics for pneumonia.

For patients with specific conditions, such as acute asthma, pneumonia, lung cancer, deterioration of lung fibrosis, or other interstitial lung disease, the recommendations include using a reservoir mask at 15 L/min if the initial SpO2 is below 85%, otherwise using nasal cannulae or a simple face mask 1. In cases of pneumothorax, aspiration or drainage may be necessary if the patient is hypoxaemic, and a reservoir mask at 15 L/min can be used if admitted for observation, aiming for 100% saturation 1.

In severe cases of respiratory distress, preparation for possible advanced airway management, including non-invasive positive pressure ventilation (CPAP or BiPAP) or endotracheal intubation, is crucial 1. This approach ensures that immediate physiological needs are addressed while diagnostic evaluation proceeds to determine the underlying cause, which is essential for definitive treatment.

From the FDA Drug Label

CLINICAL PHARMACOLOGY The prime action of beta-adrenergic drugs is to stimulate adenyl cyclase, the enzyme which catalyzes the formation of cyclic-3',5'-adenosine monophosphate (cyclic AMP) from adenosine triphosphate (ATP). In controlled clinical trials, most patients exhibited an onset of improvement in pulmonary function within 5 minutes as determined by FEV1. Clinically significant improvement in pulmonary function (defined as maintenance of a 15% or more increase in FEV1 over baseline values) continued for 3 to 4 hours in most patients and in some patients continued up to 6 hours

The initial management of shortness of breath in the emergency room (ER) may involve the use of albuterol (INH), a beta-adrenergic agonist that can produce bronchial smooth muscle relaxation.

• Onset of action: within 5 minutes
• Peak effect: approximately 1 hour
• Duration of action: 3 to 4 hours in most patients, up to 6 hours in some patients 2

From the Research

Initial Management of Shortness of Breath in the ER

The initial management of shortness of breath in the emergency room (ER) involves a comprehensive approach to identify the underlying cause and provide appropriate treatment. Some key points to consider include:

• Evaluating the patient's history and symptoms to determine the potential cause of shortness of breath 3
• Using imaging studies, such as chest X-rays or CT scans, to help diagnose the cause of shortness of breath 4, 5
• Providing oxygen therapy, which can include high-flow nasal cannula oxygen therapy, to help improve oxygen saturation and reduce respiratory distress 6, 7
• Considering the use of other treatments, such as bronchodilators or antibiotics, depending on the underlying cause of shortness of breath 4

Oxygen Therapy in the ER

Oxygen therapy is a crucial component of the initial management of shortness of breath in the ER. Some key points to consider include:

• High-flow nasal cannula oxygen therapy can be effective in reducing respiratory rate and improving oxygen saturation in patients with acute respiratory failure 6
• Nasal cannula apneic oxygenation can help prevent desaturation during endotracheal intubation and improve first-pass success attempts 7
• The use of high-flow oxygen therapy can be beneficial in patients with underlying lung pathology or high metabolic demands 7

Diagnostic Approach

A thorough diagnostic approach is essential in identifying the underlying cause of shortness of breath in the ER. Some key points to consider include:

• Evaluating the patient's history and symptoms to determine the potential cause of shortness of breath 3
• Using imaging studies, such as chest X-rays or CT scans, to help diagnose the cause of shortness of breath 4, 5
• Considering the use of other diagnostic tests, such as arterial blood gas analysis or pulmonary function tests, depending on the underlying cause of shortness of breath 4, 3