What are the Indian guidelines for managing shortness of breath?

Indian Guidelines for Managing Shortness of Breath

I was unable to locate specific Indian national guidelines for managing shortness of breath in the evidence provided. However, I can provide evidence-based management principles from international guidelines that are widely applicable and should be followed in the Indian context.

Initial Assessment and Oxygen Therapy

Target oxygen saturation of 94-98% for most patients presenting with acute shortness of breath, using nasal cannulae at 2-6 L/min or simple face mask at 5-10 L/min as initial therapy. 1

Oxygen Delivery Based on Severity:

• SpO2 below 85%: Start with reservoir mask at 15 L/min 1
• SpO2 85-93%: Nasal cannulae at 2-6 L/min or simple face mask at 5-10 L/min 1
• Patients at risk of hypercapnic respiratory failure (COPD, obesity hypoventilation): Target 88-92% saturation pending blood gas results 1

Critical Monitoring Parameters:

• Measure respiratory rate and heart rate carefully, as tachypnea and tachycardia are more common than visible cyanosis in hypoxemic patients 1
• Pulse oximetry is essential for continuous monitoring 1
• Arterial blood gas analysis should be performed if pH <7.26 or rising PaCO2 1

Condition-Specific Management

Acute Asthma Exacerbations

Administer repetitive or continuous short-acting beta-agonists (SABA) immediately, along with supplemental oxygen and oral systemic corticosteroids for moderate to severe exacerbations. 1

Severity Classification and Treatment:

• Mild (PEF ≥70% predicted): Dyspnea only with activity; inhaled SABA, possible short course oral corticosteroids 1
• Moderate (PEF 40-69% predicted): Dyspnea interferes with usual activity; frequent inhaled SABA, oral systemic corticosteroids 1
• Severe (PEF <40% predicted): Dyspnea at rest, interferes with conversation; requires ED visit, frequent SABA, oral corticosteroids, adjunctive therapies 1
• Life-threatening (PEF <25% predicted): Too dyspneic to speak; requires hospitalization/ICU, intravenous corticosteroids 1

Specific Interventions:

• Salbutamol: 2.5-5 mg via nebulizer every 4-6 hours, or 2 inhalations (90 mcg per actuation) via MDI 2, 1
• Ipratropium bromide: 0.25-0.5 mg for severe exacerbations or poor response to SABA alone 1
• Prednisolone: 30 mg/day orally for 7-14 days 1
• Intravenous magnesium sulfate or heliox: Consider if FEV1 or PEF <40% predicted after initial treatments 1

COPD Exacerbations

Nebulized bronchodilators should be driven by compressed air (not oxygen) if PaCO2 is elevated or respiratory acidosis present, with supplemental oxygen given simultaneously via nasal prongs at 1-2 L/min. 1

Treatment Protocol:

• Bronchodilators: Salbutamol 2.5-5 mg or terbutaline 5-10 mg via nebulizer; add ipratropium 0.25-0.5 mg if severe or poor response 1
• Corticosteroids: Prednisolone 30 mg/day or hydrocortisone 100 mg IV for 7-14 days 1
• Antibiotics: Indicated if increased sputum purulence, volume, or dyspnea; amoxicillin or tetracycline first-line 1
• Controlled oxygen therapy: Target SpO2 88-92% to avoid worsening hypercapnia 1

Ventilatory Support Indications:

• Non-invasive ventilation (NIV): Consider if pH <7.26 and rising PaCO2 despite optimal medical therapy 1
• Initial pressure settings: EPAP 3 cm H2O, IPAP 15 cm H2O (20 cm H2O if pH <7.25) 1
• Red flags requiring ICU consideration: pH <7.25 on optimal NIV, respiratory rate persistently >25, new onset confusion 1

Other Common Causes

Acute Heart Failure:

• Consider CPAP or NIV for pulmonary edema 1
• Target SpO2 94-98% 1

Pneumonia:

• Reservoir mask at 15 L/min if SpO2 <85%, otherwise nasal cannulae or simple face mask 1
• Target SpO2 94-98% 1

Pneumothorax:

• Requires aspiration or drainage if hypoxemic 1
• If admitted for observation without drainage, use reservoir mask at 15 L/min targeting 100% saturation (oxygen accelerates pneumothorax clearance) 1

Pulmonary Embolism:

• Most patients with minor PE are not hypoxemic and do not require oxygen 1
• If hypoxemic, target SpO2 94-98% 1

Critical Pitfalls to Avoid

• Never delay oxygen therapy while awaiting diagnosis in hypoxemic patients 1
• Avoid high-flow oxygen in COPD patients without blood gas monitoring, as this can worsen hypercapnia and respiratory acidosis 1
• Do not use rebreathing from paper bags for hyperventilation—this can cause dangerous hypoxemia 1
• Drowsiness is a predictor of impending respiratory failure—consider immediate transfer to facility with ventilatory support 1
• Confusion and agitation in COPD exacerbations may indicate worsening hypercapnia requiring urgent blood gas analysis 1

Epidemiological Context for India

In a prospective study of prehospital patients with shortness of breath in Andhra Pradesh, mortality before hospital arrival was 12%, at 48-72 hours was 27%, and at 30 days was 35% 3. Predictors of prehospital death included chest pain, recent upper respiratory infection symptoms, history of heart disease, and systolic blood pressure <90 mm Hg 3. This underscores the critical importance of early recognition and aggressive management.