What are the initial steps in managing acute breathlessness?

Initial Management of Acute Breathlessness

The initial steps in managing acute breathlessness should include assessment of oxygen saturation, administration of appropriate oxygen therapy based on target saturation ranges, and addressing the underlying cause while implementing supportive measures to relieve symptoms. 1

Initial Assessment

• Measure oxygen saturation using pulse oximetry, which must be available in all locations where emergency oxygen is used 1
• Check vital signs including respiratory rate, heart rate, and blood pressure to assess severity 2
• Consider arterial blood gas (ABG) measurement for patients with risk factors for hypercapnic respiratory failure, unexpected fall in SpO2, or clinical deterioration 1
• Identify patients at risk of hypercapnic respiratory failure (e.g., COPD, neuromuscular disease, chest wall deformities, morbid obesity) 2

Oxygen Therapy Administration

• For patients without risk of hypercapnic respiratory failure with SpO2 <94%:

  • Start with nasal cannulae (1-4 L/min) or simple face mask (5-10 L/min) to achieve target saturation of 94-98% 1
  • For severely breathless patients with SpO2 <85%, initially use reservoir mask at 15 L/min, then titrate down once stabilized 1

• For patients with risk of hypercapnic respiratory failure (especially COPD):

  • Target oxygen saturation of 88-92% 1
  • Use controlled oxygen therapy via Venturi mask (24-28%) 1
  • Monitor closely for signs of carbon dioxide retention 1

• If medium-concentration therapy fails to achieve desired saturation, change to reservoir mask and seek senior or specialist advice 1

Non-Pharmacological Interventions

• Position the patient to optimize ventilation 1, 2:

  • Sitting upright increases peak ventilation and reduces airway obstruction 1
  • Leaning forward with arms bracing a chair or knees improves ventilatory capacity 1

• Teach controlled breathing techniques 1:

  • Pursed-lip breathing: inhale through nose for several seconds, then exhale slowly through pursed lips for 4-6 seconds 1
  • Relaxing and dropping shoulders to reduce hunched posture associated with anxiety 1

• Consider use of a hand-held fan as first-line treatment when oxygen saturation is normal 2

Pharmacological Management

• For patients with bronchospasm, administer bronchodilators:

  • Ipratropium bromide via nebulizer - patient should sit in comfortable, upright position and breathe calmly and deeply until no more mist forms (5-15 minutes) 3

• For patients with end-of-life breathlessness who are distressed despite other measures:

  • Consider opioids based on patient status 1:
    • For opioid-naive patients able to swallow: morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as required 1
    • For patients already on opioids: morphine sulfate immediate-release 5-10 mg every 2-4 hours as required 1
    • For patients unable to swallow: morphine sulfate 1-2 mg subcutaneously every 2-4 hours as required 1
  • Consider concomitant use of an antiemetic and regular stimulant laxative 1

Monitoring and Escalation

• Record oxygen saturation, delivery system, and flow rate on patient monitoring charts 2

• Reassess frequently if breathlessness persists despite normal oxygen saturation 2

• Seek medical advice if 1:

  • Patient appears to need increasing oxygen therapy
  • There is a rising National Early Warning Score (NEWS)
  • Signs of respiratory deterioration are present

• All patients requiring increased oxygen dose must have ABG or earlobe blood gases within 1 hour 1

Special Situations

• For critical illness (major trauma, sepsis, shock, anaphylaxis):

  • Initiate treatment with reservoir mask at 15 L/min 1
  • Target saturation range of 94-98% 1
  • This applies even to patients with risk factors for hypercapnia pending blood gas results 1

• For cardiopulmonary resuscitation:

  • Use highest feasible inspired oxygen during CPR 1
  • Once spontaneous circulation returns and SpO2 can be monitored reliably, aim for 94-98% 1
  • If blood gas shows hypercapnic respiratory failure, reset target to 88-92% 1

• For carbon monoxide poisoning:

  • Aim for oxygen saturation of 100% using reservoir mask at 15 L/min 1
  • Note that pulse oximetry readings may be falsely normal due to carboxyhemoglobin 1

Common Pitfalls to Avoid

• Administering oxygen without monitoring saturation 1
• Targeting 100% saturation in all patients, which may be harmful in those at risk of hypercapnia 1, 4
• Delaying oxygen therapy in critically ill patients 1
• Continuing oxygen therapy without reassessment when the patient has stabilized 1, 2
• Failing to consider non-pharmacological interventions alongside oxygen therapy 1