What is the initial management for a patient presenting with shortness of breath?

Initial Management of Shortness of Breath

Begin with an immediate 'ABC' assessment (Airway, Breathing, Circulation), followed by rapid vital sign measurement including pulse oximetry, and initiate oxygen therapy if saturations are below target range while simultaneously obtaining a focused history. 1, 2

Immediate Assessment (First 5 Minutes)

Primary Survey:

• Assess airway patency and breathing adequacy - look for signs of severe respiratory distress including use of accessory muscles, inability to speak in full sentences, cyanosis, or altered mental status 1, 2
• Measure vital signs immediately: respiratory rate, pulse rate, blood pressure, and oxygen saturation via pulse oximetry 1, 2
• Obtain brief focused history from patient or family regarding: onset and duration of symptoms, history of COPD/asthma/heart failure, recent illness, chest pain, fever, or leg swelling 1, 2

Critical distinction: If the patient is unresponsive with absent or abnormal breathing (only gasping), assume cardiac arrest and immediately begin CPR - do not delay for pulse check beyond 10 seconds 1

Immediate Oxygen Therapy

For patients WITHOUT known COPD:

• Administer high-flow oxygen (10-15 L/min via non-rebreather mask) to achieve target saturation of 94-98% 1, 2

For patients WITH suspected or known COPD:

• Initially limit oxygen to 28% via Venturi mask or 2 L/min via nasal cannula until arterial blood gas results are available 1, 2
• Target oxygen saturation of 88-92% to prevent hypercapnic respiratory failure 2
• This lower target is critical as excessive oxygen can worsen CO2 retention in COPD patients 1

Common pitfall: Never withhold oxygen from a critically hypoxemic patient even with COPD - hypoxemia kills faster than hypercapnia. Start oxygen immediately and adjust based on blood gas results 1

Immediate Investigations (Within First 30-60 Minutes)

• Arterial blood gas - measure within 60 minutes of starting oxygen therapy, noting the inspired oxygen concentration (FiO₂) 2
• Chest radiograph - to identify pneumonia, pneumothorax, pulmonary edema, or other acute pathology 2
• ECG - to assess for cardiac causes including acute coronary syndrome or arrhythmias 2
• Complete blood count and basic metabolic panel within first 24 hours 2

Immediate Therapeutic Interventions

For suspected obstructive airway disease (asthma/COPD):

• Administer nebulized bronchodilators immediately - do not wait for diagnostic confirmation 1, 2
• Moderate severity: Give either β-agonist (salbutamol 2.5-5 mg) OR anticholinergic (ipratropium 0.25-0.5 mg) 2
• Severe exacerbation or poor initial response: Give BOTH β-agonist AND anticholinergic together 2

Important caveat: Bronchodilator therapy can transiently worsen V/Q mismatch and reduce blood oxygen levels immediately after administration - maintain continuous oxygen saturation monitoring 1

For suspected COPD exacerbation with significant symptoms:

• Initiate systemic corticosteroids - prednisolone 30 mg orally daily or hydrocortisone 100 mg IV if oral route not possible, for 7-14 days 2
• Start antibiotics if infection suspected - indicated by purulent sputum, fever, or increased sputum volume 2

Continuous Monitoring

• Monitor oxygen saturation continuously with pulse oximetry until patient is stable 1, 2
• Repeat arterial blood gas after any change in inspired oxygen concentration or if clinical condition deteriorates 2
• Reassess respiratory rate and work of breathing frequently - increasing respiratory rate or accessory muscle use indicates deterioration 1

Special Circumstances

Foreign body airway obstruction (choking):

• If patient has severe obstruction (cannot speak, silent cough, cyanosis), immediately perform abdominal thrusts 1
• Ask "Are you choking?" - if patient nods without speaking, this confirms severe obstruction requiring immediate intervention 1

Drowning victim:

• Provide rescue breathing as soon as victim is removed from water - this takes priority over chest compressions unless patient is in cardiac arrest 1
• Do NOT attempt abdominal thrusts or maneuvers to remove water - water does not act as an obstructive foreign body 1

Anaphylaxis with respiratory symptoms:

• Assist with administration of epinephrine auto-injector if prescribed 1
• Consider second dose if symptoms fail to improve after first dose 1