What are the initial steps in managing a patient presenting with breathlessness?

Initial Management of Breathlessness

Begin by ensuring scene safety, checking responsiveness, and immediately assessing for life-threatening causes requiring resuscitation, then measure oxygen saturation and vital signs to guide oxygen therapy and determine the need for urgent intervention. 1, 2

Immediate Assessment (First 60 Seconds)

Check for Cardiac Arrest

• Tap the patient's shoulder and shout "Are you all right?" to assess responsiveness 1
• Simultaneously check for absent or abnormal breathing (gasping does not count as normal breathing) 1
• If unresponsive with no breathing or only gasping, activate emergency response and begin CPR immediately 1
• Healthcare providers should check for a pulse, taking no more than 10 seconds—if no definite pulse is felt, start chest compressions 1

Vital Signs and Oxygen Assessment

• Measure oxygen saturation using pulse oximetry immediately in all patients presenting with breathlessness 2
• Check respiratory rate, heart rate, and blood pressure to assess severity 2
• Observe work of breathing and use of accessory muscles 2

Common pitfall: Normal oxygen saturation does not exclude serious pathology—tachypnea and increased work of breathing may indicate distress despite SpO2 >94% 3

Oxygen Therapy Decision Algorithm

For Patients WITHOUT Risk of Hypercapnic Respiratory Failure

• If SpO2 <94%, start oxygen via nasal cannula (1-4 L/min) or simple face mask (5-10 L/min) targeting 94-98% saturation 2
• Patients at risk for hypercapnic respiratory failure include those with COPD, neuromuscular disease, chest wall deformities, or morbid obesity 2

For Patients WITH Risk of Hypercapnic Respiratory Failure

• Target oxygen saturation of 88-92% using controlled oxygen via Venturi mask (24-28%) 2
• Consider arterial blood gas measurement if clinical concern persists, as pulse oximetry may not reflect ventilation adequacy 3, 2

Special Circumstances

• Critical illness: Use reservoir mask at 15 L/min targeting 94-98% 2
• Carbon monoxide poisoning: Aim for 100% saturation using reservoir mask at 15 L/min 2
• Normal oxygen saturation with persistent breathlessness: Do NOT give supplemental oxygen unless documented hypoxemia is present 3

Immediate Non-Pharmacological Interventions

Positioning

• Sit the patient upright to increase peak ventilation and reduce airway obstruction 1, 2
• Have the patient lean forward with arms bracing a chair or knees with upper body supported to improve ventilatory capacity 1, 2

Breathing Techniques

• Teach pursed-lip breathing: inhale through nose for several seconds with mouth closed, then exhale slowly through pursed lips for 4-6 seconds 1
• Instruct patient to relax and drop shoulders to reduce the hunched posture associated with anxiety 1

Anxiety Management

• Recognize that severe breathlessness often causes anxiety, which then increases breathlessness further 1
• Use a hand-held fan directed at the face as first-line symptomatic treatment when oxygen saturation is normal 3, 2

Airway Management for Unresponsive Patients

If Patient is Unresponsive but Breathing

• Open airway using head tilt-chin lift maneuver: place hand on forehead and gently tilt head back while lifting chin with fingertips 1
• Avoid head tilt if trauma to the neck is suspected 1
• Look, listen, and feel for breathing for 10 seconds before deciding breathing is absent 1
• If breathing is present, turn patient into recovery position and check for continued breathing 1

If Patient is Not Breathing

• Give 2 effective rescue breaths after ensuring head tilt and chin lift, pinching nose closed, and creating a good seal around the mouth 1
• Each breath should take 1.5-2 seconds and make the chest rise 1
• Remove any visible obstruction from the mouth, including dislodged dentures 1

Monitoring and Documentation

• Record oxygen saturation, delivery system, and flow rate on patient monitoring charts 2
• Reassess frequently if breathlessness persists despite interventions 2
• Seek medical advice if: patient appears to need increasing oxygen therapy, there is a rising National Early Warning Score (NEWS), or signs of respiratory deterioration are present 2

Critical Pitfalls to Avoid

• Never administer oxygen without monitoring saturation 2
• Do not target 100% saturation in all patients—this can be harmful in those at risk of hypercapnic respiratory failure 2
• Do not delay oxygen therapy in critically ill patients 2
• Do not continue oxygen therapy without reassessment once the patient has stabilized 2
• Do not assume normal oxygen saturation means the patient is stable—assess respiratory rate and work of breathing 3