What is the initial management for a patient experiencing difficulty breathing in a ward setting?

Initial Ward Management of Difficulty Breathing

Position the patient upright or semi-recumbent (30-45° head elevation), immediately measure oxygen saturation with pulse oximetry, and initiate supplemental oxygen if SpO2 is below target range (94-98% for most patients, 88-92% for those at risk of hypercapnic respiratory failure). 1, 2

Immediate Assessment (ABC Approach)

• Ensure airway patency first – check for obstruction, stridor, or signs of laryngeal compromise 1, 2
• Measure vital signs immediately: respiratory rate, heart rate, blood pressure, temperature, and oxygen saturation via pulse oximetry 3, 1, 2
• Position patient upright (sitting or 30-45° elevation) to optimize respiratory mechanics and reduce aspiration risk 3, 2
• Monitor continuously with pulse oximetry until the patient stabilizes – clinical signs like cyanosis are unreliable 2

Critical pitfall: Never ignore respiratory complaints even if objective signs are absent, as serious conditions may present with minimal initial findings 4

Oxygen Therapy Protocol

Target Oxygen Saturations

• Standard patients: Target SpO2 94-98% 3, 1, 2
• Patients at risk of hypercapnic respiratory failure (COPD, obesity hypoventilation, neuromuscular disease, chest wall deformities): Target SpO2 88-92% 3, 1, 2

Oxygen Delivery Methods

For standard patients with SpO2 <94%:

• Start with nasal cannulae at 1-4 L/min or simple face mask at 5-10 L/min 1, 2
• Titrate upward to achieve target saturation 3, 1

For patients at risk of hypercapnic respiratory failure:

• Use controlled oxygen delivery with Venturi mask: 24% at 2-3 L/min or 28% at 4 L/min 1, 2
• Alternatively, use nasal cannulae at 1-2 L/min 2
• Critical warning: Uncontrolled high-flow oxygen in COPD patients causes hypercapnic respiratory failure 2

For critical illness or severe hypoxemia:

• Use reservoir mask at 15 L/min initially 1
• Target 94-98% once supplemental oxygen is established 1

Humidification

• Consider humidification when oxygen flows exceed 4 L/min to prevent airway drying and improve patient comfort 5

Condition-Specific Initial Management

COPD Exacerbation

• Controlled oxygen targeting 88-92% SpO2 2
• Bronchodilators: Administer short-acting beta-agonists (salbutamol/albuterol) and anticholinergics (ipratropium) via nebulizer 2, 6, 7
• Consider arterial blood gas if risk of hypercapnia 1

Acute Heart Failure

• Oxygen if SpO2 <90%, targeting 94-98% once supplemented 2
• Immediate IV diuretics 2
• Monitor daily weights and fluid balance 2

Asthma Exacerbation

• Oxygen to correct hypoxemia, targeting 94-98% 2
• Repetitive or continuous short-acting beta-agonists (salbutamol) 2, 6
• Bronchodilator therapy is safe and effective for acute shortness of breath in asthmatics 3

Monitoring Requirements

• Titrate oxygen continuously to maintain target saturation – avoid both under-oxygenation and excessive oxygen 2
• Record oxygen saturation, delivery system, and flow rate on monitoring charts 1
• Reassess frequently if breathlessness persists despite normal oxygen saturation 1
• Monitor for increasing oxygen requirements as a sign of deterioration 1

Escalation Criteria – When to Call for Help

Consider non-invasive ventilation (NIV) or ICU involvement if:

• Respiratory rate >25 breaths/min despite initial management 2
• SpO2 <90% despite supplemental oxygen 2
• Persistent hypoxemia after 30 minutes of medical therapy 2
• COPD with pH <7.35 and PCO2 >6 kPa after initial treatment 2
• Systolic BP <90 mmHg or signs of hypoperfusion 2
• Rising National Early Warning Score (NEWS) 1

Non-Pharmacological Interventions

• Teach controlled breathing techniques: pursed-lip breathing, relaxing shoulders to reduce anxiety-related hunched posture 1
• Use hand-held fan as first-line treatment when oxygen saturation is normal but breathlessness persists 1
• Ensure calm environment to reduce anxiety-driven respiratory distress 1

Critical Pitfalls to Avoid

• Never give uncontrolled high-flow oxygen to COPD patients – this precipitates hypercapnic respiratory failure 2
• Never abruptly stop oxygen in hypercapnic patients – causes rebound hypoxemia 2
• Never administer oxygen without monitoring saturation 1
• Never target 100% saturation in all patients – hyperoxia can be harmful 1
• Never delay oxygen therapy in critically ill patients while waiting for investigations 1
• Never continue oxygen without reassessment once the patient has stabilized 1

Documentation

• Record all oxygen therapy given (concentration, flow rate, delivery device, duration) even in emergency situations where formal prescription was not possible 3
• Document target saturation range and rationale for chosen targets 1
• Note response to therapy and any escalation of care 1