What is the guideline-directed algorithm for evaluating Shortness of Breath (SOB) in the emergency department?

From the Guidelines

The evaluation of shortness of breath (SOB) in the emergency department should begin with a rapid 'ABC' assessment, followed by obtaining a quick history and measuring vital signs, including pulse rate, respiratory rate, and pulse oximetry, as suggested by the British Thoracic Society guideline for oxygen use in adults in healthcare and emergency settings 1. The initial assessment of a breathless patient should include:

• Recording of pulse rate and respiratory rate in all cases
• Pulse oximetry to assess for hypoxaemia
• A brief history taken from the patient or other informant
• Disease-specific measurements, such as peak expiratory flow in asthma or blood pressure in cardiac disease This initial assessment is crucial in identifying potential life-threatening conditions and guiding further management.

The next steps in the workup of SOB in the emergency department should include:

• Providing supplemental oxygen if necessary, targeting SpO2 > 94% (or 88-92% for COPD patients)
• Considering non-invasive ventilation (CPAP/BiPAP) or intubation if severe respiratory distress is present
• Ordering diagnostic tests, such as chest X-ray, ECG, complete blood count, basic metabolic panel, and cardiac enzymes (troponin)
• Using point-of-care ultrasound to evaluate for pneumothorax, pleural effusion, pulmonary edema, or right heart strain
• Considering further testing, such as D-dimer for suspected pulmonary embolism or echocardiogram for suspected cardiac causes

A systematic approach to the evaluation of SOB in the emergency department, as outlined above, is essential for rapid identification and treatment of life-threatening conditions, while also establishing the correct diagnosis for definitive management 1. Treatment should be directed at the underlying cause, with options including:

• Bronchodilators and steroids for asthma/COPD exacerbations
• Diuretics for heart failure
• Antibiotics for pneumonia
• Anticoagulation for pulmonary embolism
• Appropriate management for pneumothorax if present By following this guideline-directed algorithm, emergency department clinicians can ensure that patients with SOB receive timely and effective care.

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 initial assessment and treatment should follow the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach 2.
• Ensuring adequate oxygenation and ventilation is crucial, especially in patients with acute heart failure (AHF) 3.
• The clinical presentation alone can be adequate to make a diagnosis in 66 percent of patients with dyspnea 4.
• Patients' descriptions of the sensation of dyspnea, associated symptoms, and risk factors should be considered 4.
• Examination findings, such as jugular venous distention, decreased breath sounds or wheezing, pleural rub, and clubbing, can be helpful in making the diagnosis 4.

Initial Testing and Evaluation

• Initial testing in patients with chronic dyspnea includes:
  • Chest radiography
  • Electrocardiography
  • Spirometry
  • Complete blood count
  • Basic metabolic panel 4
• Measurement of brain natriuretic peptide levels may help exclude heart failure 4.
• D-dimer testing may help rule out pulmonary emboli 4.
• Pulmonary function studies can be used to identify emphysema and interstitial lung diseases 4.
• Computed tomography of the chest is the most appropriate imaging study for diagnosing suspected pulmonary causes of chronic dyspnea 4.

Further Evaluation and Diagnosis

• Right heart catheterization or bronchoscopy may be needed to diagnose pulmonary arterial hypertension or certain interstitial lung diseases 4.
• A literature review of causes of dyspnea other than reversible airway disease can provide further guidance on evaluation and diagnosis 5.