What is the initial approach to a patient presenting with shortness of breath?

Initial Approach to Shortness of Breath

Begin by immediately assessing responsiveness and breathing pattern while simultaneously checking oxygen saturation—if the patient is unresponsive with absent or only gasping respirations, activate emergency response and start CPR immediately; if responsive, position upright, apply oxygen targeting 94-98% saturation (or 88-92% if COPD/hypercapnic risk), and rapidly evaluate for life-threatening causes. 1

Immediate Life-Threatening Assessment (First 10 Seconds)

Check responsiveness by tapping the shoulder and shouting "Are you all right?" 2, 1

• If unresponsive with no breathing or only gasping: Healthcare providers check pulse for maximum 10 seconds—if no definite pulse, begin chest compressions immediately 2
• Gasping does not count as normal breathing and indicates cardiac arrest 2
• Activate emergency response before or immediately after starting CPR 2

Critical pitfall: Agonal breathing (slow, irregular gasping) is present in 40-60% of cardiac arrests and commonly causes rescuers to misdiagnose patients as not being in arrest 2

Vital Signs and Oxygen Assessment (First 1-2 Minutes)

Measure oxygen saturation immediately using pulse oximetry in all breathless patients 2, 1

• Record respiratory rate, heart rate, blood pressure, and temperature 2
• Document inspired oxygen device and flow rate on monitoring charts 2, 1
• A sudden drop ≥3% in saturation should prompt fuller assessment even within target range 2

Oxygen Therapy Initiation

For patients WITHOUT COPD or hypercapnic risk (most patients):

• Target oxygen saturation: 94-98% 2, 1
• Start with nasal cannula 1-4 L/min or simple face mask 5-10 L/min 1
• Use highest possible oxygen concentration if shock, sepsis, major trauma, drowning, anaphylaxis, or cardiac arrest 2

For patients WITH COPD, morbid obesity, cystic fibrosis, chest wall deformities, or neuromuscular disorders:

• Target oxygen saturation: 88-92% 2, 1
• Use controlled oxygen via Venturi mask at 24-28% 1
• This prevents hypercapnic respiratory failure while treating hypoxemia 2

Critical exception: In carbon monoxide poisoning, give maximum oxygen via bag-valve mask or reservoir mask regardless of oximetry reading, as pulse oximeters cannot differentiate carboxyhemoglobin from oxyhemoglobin 2

Positioning and Airway Management

Position the patient upright to maximize ventilation 1

• Fully conscious hypoxemic patients should maintain the most upright posture possible, as oxygenation is reduced when supine 2
• Have patient lean forward with arms bracing on chair or knees to improve ventilatory capacity 1
• Only immobilize if skeletal or spinal trauma suspected 2

Open the airway if patient has decreased consciousness:

• Use head tilt-chin lift maneuver: place hand on forehead, gently tilt head back while lifting chin with fingertips 1
• Avoid head tilt if neck trauma suspected 1
• If not breathing adequately, give 2 rescue breaths (1.5-2 seconds each, making chest rise) after pinching nose and creating mouth seal 1

Breathing Techniques for Conscious Patients

Teach pursed-lip breathing to reduce work of breathing 1:

• Inhale through nose for several seconds with mouth closed
• Exhale slowly through pursed lips for 4-6 seconds
• Instruct patient to relax and drop shoulders to reduce anxiety-related hunched posture 1

Specific Life-Threatening Scenarios

Asthma with acute shortness of breath: Assist with administration of inhaled bronchodilators 2

Drowning victims: Provide rescue breathing as soon as removed from water; give 5 cycles (2 minutes) of CPR before activating EMS if alone 2

• Do NOT perform abdominal thrusts or attempt to clear water from airway—this delays CPR and can cause aspiration 2

Hypothermia: Begin CPR immediately without waiting to check temperature or rewarm; remove wet clothes and provide warm humidified oxygen if available 2

Foreign body airway obstruction: Intervene only if severe obstruction (silent cough, cyanosis, inability to speak/breathe, universal choking sign) 2

Monitoring and Escalation Triggers

Reassess frequently and document changes 1

Seek immediate medical assistance if 1:

• Patient requires increasing oxygen therapy to maintain target saturation
• Rising National Early Warning Score (NEWS)
• Signs of respiratory deterioration despite interventions
• Respiratory rate >25 or <8 breaths/minute 2

Common pitfall: Non-hypoxemic breathless patients do not benefit from oxygen therapy—focus on treating underlying cause rather than empirically giving oxygen 2

Differential Diagnosis Considerations

While stabilizing the patient, rapidly consider:

• Cardiac: Acute coronary syndrome, heart failure, cardiac arrest 3
• Pulmonary: Pneumonia, COPD exacerbation, pulmonary embolism, pneumothorax 3
• Airway: Foreign body, anaphylaxis, angioedema 2
• Other: Anemia, metabolic acidosis, anxiety 3

History and physical examination often lead to correct diagnosis, but 30-50% of cases require additional diagnostic studies including biomarkers and imaging 3