From the Guidelines
To evaluate shortness of breath (SOB) in the emergency department, begin with a rapid assessment of airway, breathing, and circulation to identify life-threatening conditions requiring immediate intervention, as suggested by the British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings 1. When approaching a patient with SOB, it is crucial to prioritize a quick and thorough initial assessment. This includes:
- Recording of pulse rate, respiratory rate, and pulse oximetry, as these are essential components of the initial evaluation 1
- Obtaining a brief history from the patient or other informant to gather information about the onset, duration, and severity of symptoms, as well as any associated symptoms or past medical history
- Performing disease-specific measurements, such as peak expiratory flow in asthma or blood pressure in cardiac disease, to guide further management
The initial assessment should be followed by a focused physical examination, including:
- Assessment of work of breathing and mental status
- Evaluation of the use of accessory muscles
- Auscultation of lung sounds to identify any abnormalities, such as wheezes or crackles
Based on the results of the initial assessment and physical examination, the next steps in management may include:
- Providing supplemental oxygen to target a SpO2 >94% (or 88-92% for COPD patients) 1
- Considering non-invasive ventilation or intubation for severe respiratory distress
- Ordering diagnostic tests, such as ECG, chest X-ray, complete blood count, basic metabolic panel, troponin, BNP, and arterial blood gas, to help identify the underlying cause of SOB
- Initiating treatment for specific conditions, such as pulmonary embolism, heart failure, COPD/asthma exacerbations, or pneumonia, based on the results of the diagnostic tests and clinical evaluation.
From the Research
Guideline Directed Algorithm for Workup of SOB in the Emergency Department
The workup of shortness of breath (SOB) in the emergency department can be approached using a systematic algorithm. The following steps outline a guideline-directed approach:
- Initial Assessment: The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is widely accepted for immediate assessment and treatment of patients with SOB 2.
- Airway and Breathing Management: Ensuring adequate oxygenation and ventilation is crucial in the management of patients with SOB, particularly those with acute heart failure (AHF) 3.
- Diagnostic Evaluation: A shortness-of-breath biomarker panel, including troponin I, myoglobin, creatinine kinase-myocardial band isoenzyme (CK-MB), D-dimer, and B-type natriuretic peptide (BNP), can help identify the underlying cause of SOB 4.
- Clinical Presentation: The clinical presentation alone can be adequate to make a diagnosis in 66 percent of patients with dyspnea 5.
- Initial Testing: Initial testing in patients with SOB includes chest radiography, electrocardiography, spirometry, complete blood count, and basic metabolic panel 5.
- Further Evaluation: Measurement of brain natriuretic peptide levels may help exclude heart failure, and D-dimer testing may help rule out pulmonary emboli 5.
- Pulmonary Function Studies: Pulmonary function studies can be used to identify emphysema and interstitial lung diseases 5.
- Imaging Studies: Computed tomography of the chest is the most appropriate imaging study for diagnosing suspected pulmonary causes of SOB 5.
- Invasive Testing: Right heart catheterization or bronchoscopy may be needed to diagnose pulmonary arterial hypertension or certain interstitial lung diseases 5.
Considerations for Chronic Dyspnea
For patients with chronic dyspnea, the following considerations should be taken into account:
- Multifactorial Etiology: The etiology of dyspnea is multifactorial in about one-third of patients 5.
- Risk Factors: Risk factors, such as smoking, chemical exposures, and medication use, should be considered in the evaluation of chronic dyspnea 5.
- Associated Symptoms: Associated symptoms, such as jugular venous distention, decreased breath sounds or wheezing, pleural rub, and clubbing, may be helpful in making the diagnosis 5.