What is the approach to Shortness Of Breath (SOB)?

From the Guidelines

Shortness of breath (SOB) should be approached by first identifying the underlying cause, which can be cardiovascular, pulmonary, or a combination of both, and then providing symptomatic treatment.

Causes of SOB

• The differential diagnosis of SOB encompasses a wide variety of pathologies, including cardiovascular, pulmonary, gastrointestinal, neuromuscular, systemic, and psychogenic disorders 1.
• A multifactorial etiology is reported in up to a third of patients, with cardiovascular and pulmonary etiologies being the most common 1.

Evaluation of SOB

• The initial evaluation of SOB is aimed at determining whether the cause is related to cardiovascular disease, pulmonary disease, a combination of both, or neither 1.
• A chest radiograph will typically be performed in the initial workup, and the results can help guide further investigation 1.
• Laboratory tests, such as blood work and pulmonary function tests, may also be necessary to determine the underlying cause of SOB 1.

Treatment of SOB

• Symptomatic treatment of SOB is based on the underlying cause, and may include bronchodilators, oxygen therapy, and opioids 1.
• Opioids, such as oral low-dose morphine, have been shown to be effective in reducing breathlessness in patients with chronic obstructive pulmonary disease (COPD) and heart failure (HF) 1.
• Non-pharmacological interventions, such as breathing training, relaxation techniques, and exercise, may also be helpful in managing SOB 1.

Special Considerations

• In patients with heart failure, SOB can be related to hemodynamic status, skeletal myopathy, and chronic or acute comorbidities 1.
• In these patients, optimizing guideline-recommended treatment of HF and concomitant disease is essential, and non-pharmacological and pharmacological symptomatic treatment should be pursued as needed 1.

From the Research

Approach to Shortness Of Breath (SOB)

The approach to Shortness Of Breath (SOB) involves a combination of assessment, resuscitation, and diagnosis.

• The management of an acutely short of breath (ASOB) patient must follow an algorithm incorporating simultaneous assessment and resuscitation 2.
• A formal diagnosis guides risk stratification, prognostication, and treatment, but it must not delay resuscitation 2.
• The use of a shortness-of-breath point-of-care biomarker panel can help identify patients with heart failure, acute myocardial infarction, and pulmonary embolism 3.
• The panel can increase the sensitivity and specificity of diagnosis, but its addition may not improve the overall diagnostic accuracy 3.

Assessment and Diagnosis

• The assessment of SOB involves evaluating the patient's history, physical examination, and laboratory results 2, 4.
• The differential diagnosis of SOB is broad and includes cardiac, pulmonary, and other causes 2, 4.
• The use of diagnostic prediction models and the Netherlands Triage Standard (NTS) urgency classification can help identify patients with urgent diagnoses 5.
• The development of patient-reported outcome instruments, such as the Shortness of Breath with Daily Activities (SOBDA) questionnaire, can help evaluate the impact of therapy on SOB and assess how SOB affects daily activities 6.

Management and Treatment

• The management of SOB involves a combination of pharmacological and non-pharmacological interventions 2.
• The use of oxygen therapy, bronchodilators, and other medications can help alleviate symptoms and improve outcomes 2.
• The development of educational programs for triage nurses and general practitioners can help improve the accuracy and safety of telephone triage for patients with SOB 5.