Treatment of Difficulty Breathing
Begin immediate assessment of vital signs and respiratory status, then initiate treatment based on the underlying cause while providing supplemental oxygen if SpO2 <90-92%. 1, 2
Immediate Assessment and Stabilization
Measure respiratory rate, oxygen saturation, blood pressure, heart rate, and assess work of breathing within the first minutes of patient contact. 1 Look specifically for:
- Signs of hypoxemia: SpO2 <90% requires immediate oxygen therapy 1, 2
- Signs of respiratory distress: inability to tolerate supine position, use of accessory muscles, altered mental status 1
- Signs of hypoperfusion: cool extremities, narrow pulse pressure, confusion 1
- Cardiac rhythm abnormalities on continuous ECG monitoring 1
Provide supplemental oxygen immediately if SpO2 <90%, but avoid routine oxygen administration in non-hypoxemic patients (SpO2 ≥92%) as it does not relieve dyspnea. 1, 2 Oxygen can be delivered via nasal cannula, face mask, or high-flow systems depending on severity. 3
Non-Pharmacological Interventions (Initiate Immediately)
Position the patient upright with head elevated or in the "coachman's seat" position (leaning forward with arms braced), as this improves ventilatory capacity and reduces airway obstruction. 3, 2
Apply cooling measures to the face using a handheld fan directed at the patient's face, as this reduces the sensation of breathlessness. 3, 2, 4
Teach pursed-lip breathing: instruct the patient to inhale through the nose for several seconds with mouth closed, then exhale slowly through pursed lips for 4-6 seconds. 3 This technique relieves breathlessness perception during acute episodes.
Encourage relaxation of shoulders to reduce the hunched posture associated with anxiety-driven breathlessness. 3
Diagnostic Evaluation (Concurrent with Treatment)
Obtain a 12-lead ECG immediately, as it is rarely normal in cardiac causes and is necessary to exclude ST-elevation MI. 1
Perform chest radiography to rule out alternative causes, though recognize it may be normal in nearly 20% of acute heart failure cases. 1
Assess for volume overload by examining for peripheral edema, audible rales, elevated jugular venous pressure, and consider bedside thoracic ultrasound for B-lines if expertise is available. 1
Order laboratory tests including complete blood count, basic metabolic panel, and relevant biomarkers (BNP/NT-proBNP) immediately and concurrently with clinical assessment. 1, 4
Cause-Specific Pharmacological Treatment
For Bronchospasm/Reversible Airway Obstruction
Administer albuterol 2.5 mg via nebulizer over 5-15 minutes for patients ≥2 years old with reversible obstructive airway disease. 5 This can be repeated three to four times daily as needed. 5
For Volume Overload/Congestive Heart Failure
If systolic blood pressure >140 mmHg with signs of congestion, initiate vasodilators. 1
If signs of volume overload are present (edema, rales, elevated JVP), administer loop diuretics (furosemide). 1
For Severe Breathlessness at End of Life or Refractory Cases
For moderate to severe breathlessness causing distress, initiate low-dose opioids as the only pharmacological agent with sufficient evidence for dyspnea palliation. 3, 2, 4
Dosing for opioid-naïve patients:
- Oral: Morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as needed, OR morphine sulfate modified-release 5 mg twice daily (maximum 30 mg daily) 3, 2
- Parenteral (if unable to swallow): Morphine sulfate 1-2 mg subcutaneously every 2-4 hours as required 3
For patients already taking opioids for pain: Give morphine sulfate immediate-release 5-10 mg every 2-4 hours as needed, or one-twelfth of the 24-hour pain dose, whichever is greater. 3
Concomitantly prescribe an antiemetic (such as haloperidol) and a regular stimulant laxative (such as senna) when initiating opioids. 3
If estimated glomerular filtration rate (eGFR) <30 mL/min, use equivalent doses of oxycodone instead of morphine. 3
For Inflammatory Airway Edema
If upper airway obstruction or stridor develops from direct airway injury (surgical/anesthetic/thermal), administer steroids equivalent to hydrocortisone 100 mg every 6 hours, starting as soon as possible and continuing for at least 12 hours. 3 Single-dose steroids immediately before the event are ineffective. 3
Consider nebulized epinephrine 1 mg to reduce airway edema if upper respiratory obstruction develops. 3
Respiratory Support Escalation
If respiratory distress persists despite initial interventions, initiate non-invasive ventilation (CPAP or BiPAP). 1
Ensure a difficult airway cart is immediately available with equipment for advanced airway management if deterioration occurs. 3
Keep the patient nil per os (NPO) if airway compromise is present, as laryngeal competence may be impaired despite full consciousness. 3
Critical Pitfalls to Avoid
Never ignore a patient who is agitated or complains of difficulty breathing, even if objective signs are absent—this is often the first warning of impending respiratory failure. 3
Do not delay treatment while awaiting complete diagnostic workup, as time-to-treatment is critical in acute presentations. 1
Do not assume a normal chest radiograph rules out pathology—it may be normal in nearly 20% of acute heart failure cases. 1
Do not administer oxygen routinely to non-hypoxemic patients (SpO2 ≥92%), as it does not relieve dyspnea and may delay appropriate treatment. 2
If a previously effective treatment regimen fails to provide relief, this is a sign of seriously worsening disease requiring immediate reassessment. 5
Follow-Up Management
For chronic or persistent dyspnea despite initial improvement, optimize treatment of the underlying disease (heart failure medications, inhaled bronchodilators for obstructive disease, etc.). 1, 4
Consider pulmonary rehabilitation and exercise training for patients with chronic dyspnea and reduced functional capacity. 4
If dyspnea remains refractory despite optimal treatment of underlying pathophysiology, consider palliative care consultation for symptom management expertise. 2, 4