What is the hospital workup for a patient presenting with facial swelling and shortness of breath (SOB)?

Hospital Workup for Facial Swelling and Shortness of Breath

Immediately assess airway patency, initiate continuous monitoring with pulse oximetry and vital signs, obtain an ECG, and administer supplemental oxygen if hypoxemic, while simultaneously pursuing diagnostic workup to differentiate between life-threatening causes including angioedema, superior vena cava syndrome, cardiac disease, and pneumomediastinum.

Immediate Assessment and Stabilization

ABC Assessment and Vital Signs

• Perform an immediate "ABC" assessment focusing on airway patency, as facial swelling with dyspnea may indicate impending airway compromise 1
• Measure pulse rate, respiratory rate, blood pressure, and continuous pulse oximetry in all patients presenting with shortness of breath 1
• Position the patient upright and administer high-flow humidified oxygen if oxygen saturation is below target range 2
• Monitor for warning signs including stridor, obstructed breathing pattern, or agitation, which should never be ignored even if objective signs initially appear absent 1, 2

Critical Initial Interventions

• Ensure continuous cardiac monitoring is available, as dyspnea with edema may indicate cardiac pathology 1
• Have difficult airway equipment immediately available given the risk of progressive airway compromise with facial swelling 1
• Consider end-tidal carbon dioxide monitoring to detect early airway obstruction 2

Diagnostic Workup Algorithm

Immediate Laboratory Studies

• Complete blood count, comprehensive metabolic panel including creatinine and albumin, and cardiac biomarkers (troponin) to evaluate for renal causes of edema, cardiac involvement, or systemic illness 3, 1
• Urine protein-to-creatinine ratio if nephrotic syndrome is suspected based on hypoalbuminemia 3
• Complement levels (C1, C4) and C1-esterase inhibitor levels if angioedema is suspected, particularly in patients with recurrent episodes or family history 4

Immediate Imaging Studies

• Obtain a chest radiograph immediately to evaluate for pneumomediastinum, subcutaneous emphysema, cardiac silhouette enlargement, or pulmonary edema 5, 6
• Perform an ECG in all patients with dyspnea and edema, as clinical manifestations may indicate Lyme carditis (if epidemiologically appropriate) or other cardiac pathology including heart failure 1
• If chest radiograph shows mediastinal widening or subcutaneous emphysema, obtain CT imaging of the chest and neck to evaluate extent of air dissection and identify underlying cause 6
• Consider neck ultrasound or CT if goiter or superior vena cava syndrome is suspected based on clinical presentation 7

Medication History

• Obtain detailed medication history with specific attention to ACE inhibitors, as angioedema from ACE inhibitors can present with facial swelling and dyspnea even after prolonged use 4
• Inquire about clozapine use, as respiratory symptoms may indicate laryngeal dystonia or other serious adverse effects 2
• Document use of other sedating medications that may contribute to respiratory depression 2

Differential Diagnosis Framework

Life-Threatening Causes Requiring Immediate Recognition

Angioedema (ACE inhibitor-induced or hereditary):

• Presents with facial/tongue swelling and potential airway compromise 4
• May have normal complement levels in ACE inhibitor-induced cases 4
• Requires immediate airway management and discontinuation of offending agent 4

Cardiac Causes:

• Heart failure with preserved ejection fraction can present with dyspnea and edema 1
• Lyme carditis presents with dyspnea, edema, palpitations, and may have PR prolongation >300ms requiring hospital admission with continuous monitoring 1
• Obtain echocardiogram if cardiac etiology suspected to assess ejection fraction, wall thickness, and estimated pulmonary artery pressures 1

Pneumomediastinum/Subcutaneous Emphysema:

• Can occur after physical exertion, Valsalva maneuvers, or barotrauma 5, 6
• Presents with facial swelling, voice changes, chest pain, and dyspnea 5, 6
• Diagnosed on chest imaging showing air in mediastinum and soft tissues 6

Superior Vena Cava Syndrome:

• Presents with facial swelling, dysphagia, and dyspnea 7
• May be caused by mediastinal masses including goiter 7
• Requires urgent imaging to identify cause and degree of obstruction 7

Non-Cardiac Mimics to Consider

• Renal disease (nephrotic syndrome) presenting with hypoalbuminemia, proteinuria, and edema 3
• Liver disease causing hypoalbuminemia and fluid retention 1
• Chronic venous insufficiency 1

Monitoring and Disposition

Admission Criteria

• Any patient with significant PR prolongation (>300ms), arrhythmias, or clinical manifestations of myopericarditis requires hospital admission with continuous ECG monitoring 1
• Patients with airway compromise or risk of progression should remain in a monitored setting with immediate access to airway management equipment 1
• Consider ICU admission for severe respiratory distress, hemodynamic instability, or progressive airway swelling 1

Ongoing Monitoring

• Continue pulse oximetry and vital signs monitoring until patient is stable 1
• Serial respiratory rate measurements, as this is a critical indicator of respiratory status 1
• A pulse oximeter alone is insufficient for monitoring ventilation and should not be relied upon as the sole monitor 1

Common Pitfalls

• Dismissing subjective complaints of breathing difficulty when objective signs are initially absent—this can delay recognition of progressive airway compromise 1, 2
• Treating presumed allergic reaction without considering alternative diagnoses like ACE inhibitor angioedema, which does not respond to antihistamines or corticosteroids 3, 4
• Failing to obtain medication history, particularly ACE inhibitors, which may have been started remotely 4
• Assuming all dyspnea with edema represents heart failure without excluding renal, hepatic, or other systemic causes 1