What is the SOAP approach for a patient presenting with dyspnea?

SOAP Approach for Dyspnea

Immediately assess vital signs including respiratory rate, oxygen saturation, blood pressure, heart rate, and temperature, while simultaneously initiating continuous monitoring with pulse oximetry and ECG to identify life-threatening conditions. 1

Subjective Assessment

Obtain focused history targeting the most common etiologies:

• Cardiac causes: Ask about orthopnea (inability to lie flat), paroxysmal nocturnal dyspnea, peripheral edema, chest pain, and history of heart failure or coronary disease 2
• Pulmonary causes: Inquire about cough, sputum production, wheezing, smoking history, occupational exposures, and known asthma or COPD 2, 3
• Timing and onset: Determine if dyspnea occurs at rest, with minimal activity, or only with exertion, as this helps differentiate systolic heart failure (rest and activity) from diastolic dysfunction (primarily exercise) 2
• Associated symptoms: Evaluate for diaphoresis (suggests acute cardiac event), fever (infection), anxiety/panic (behavioral factors), and leg swelling 2, 1
• Medication review: Identify drugs that may cause dyspnea or contribute to underlying conditions 3

Quality descriptors matter: Patients may describe "air hunger" (inability to increase ventilation), "effort of breathing" (physical tiredness), or "chest tightness" (constriction sensation) 2

Objective Assessment

Physical examination priorities:

• Respiratory distress signs: Document use of accessory muscles, nasal flaring, tachypnea, paradoxical breathing, and ability to speak in full sentences 2, 1
• Cardiovascular findings: Check for jugular venous distention, cardiac murmurs, extra heart sounds (S3 gallop in heart failure), irregular rhythm, cool extremities, narrow pulse pressure, and altered mental status indicating hypoperfusion 1, 4
• Pulmonary findings: Auscultate for decreased breath sounds, wheezing, crackles, pleural rub, and assess for clubbing 4
• Position tolerance: Note if patient can tolerate supine position or requires upright positioning 1

Initial diagnostic workup (first-line tests):

• 12-lead ECG immediately to exclude ST-elevation MI and detect arrhythmias or ischemia—rarely normal in acute cardiac events 1
• Chest radiograph to identify pulmonary edema, pneumonia, pneumothorax, pleural effusion, or cardiac enlargement (note: normal in 20% of acute heart failure cases) 1, 5
• Complete blood count to assess for anemia (decreased oxygen carrying capacity) 2, 5
• Basic metabolic panel for electrolyte abnormalities, renal dysfunction, and metabolic acidosis 2, 5
• Brain natriuretic peptide (BNP) if available: >100 pg/mL has 96% sensitivity for heart failure 1, 6
• Pulse oximetry continuously; obtain arterial blood gas if severe respiratory distress or altered mental status present 1
• Spirometry to identify obstructive or restrictive patterns 5

Second-line testing if diagnosis unclear:

• Echocardiography for structural heart disease and valvular abnormalities 6, 5
• Pulmonary function tests for detailed lung mechanics 5
• Computed tomography of chest for interstitial lung disease or pulmonary embolism 5, 4
• D-dimer to help rule out pulmonary emboli 4

Assessment (Differential Diagnosis)

Most common causes account for majority of cases:

• Cardiac: Heart failure (systolic/diastolic dysfunction), coronary artery disease, valvular disease, arrhythmias 2, 5
• Pulmonary: Asthma, COPD, pneumonia, interstitial lung disease, pleural effusion, pneumothorax 2, 5
• Other: Anemia, metabolic acidosis, obesity, severe kyphoscoliosis, neuromuscular weakness (myasthenia gravis, Guillain-Barré), behavioral factors (hyperventilation syndrome, anxiety, panic attacks) 2

Note that one-third of patients have multifactorial etiology, and most cardiopulmonary disease states involve both increased respiratory drive and impaired mechanics. 2, 4

Plan

Immediate Stabilization

Oxygen therapy: Administer if saturation <90% or based on clinical judgment for respiratory distress 1

• For suspected COPD patients over 50: Target saturation 88-92% using 28% Venturi mask or 1-2 L/min nasal cannula (not high-flow) to avoid CO2 retention 6

Non-invasive ventilation (BiPAP/CPAP): Use for severe respiratory distress in patients with adequate mental status 1

Disease-Specific Treatment

The initial focus must be optimizing treatment of the underlying disease: 2

For heart failure with systolic BP >140 mmHg:

• First-line: Vasodilators (nitroglycerin) 1
• Add: Loop diuretics (furosemide) for volume overload 1

For heart failure with systolic BP 90-140 mmHg:

• Primary therapy: Loop diuretics (furosemide) 1
• Avoid vasodilators if BP not elevated 1

For COPD/asthma exacerbations:

• Inhaled bronchodilators and corticosteroids 2, 6
• Antibiotics based on severity and risk factors 1

For pneumonia:

• Antibiotics based on severity and risk factors 1

For anemia:

• Address underlying cause and consider transfusion if severe 2

Symptomatic Management (When Underlying Disease Optimized)

Non-pharmacological interventions (implement first):

• Cool air directed at face: Use handheld fans or open windows—randomized controlled trial demonstrated breathlessness reduction 2, 6
• Optimal positioning: Coachman's seat, elevation of upper body 2, 6
• Respiratory training and breathing techniques 2, 6
• Walking aids or frames to reduce respiratory muscle demand 6
• Patient and family education to reduce helplessness and anxiety 2

Pharmacological management for refractory dyspnea:

Opioids are the only pharmacological agents with sufficient evidence and are first-line for symptomatic dyspnea: 2, 6

• Opioid-naïve patients: Start morphine 2.5-10 mg PO every 2-4 hours as needed 6
• Patients on chronic opioids: Increase dose by 25% for breakthrough dyspnea 2, 6
• Mechanism: Reduces unpleasantness of dyspnea without causing relevant respiratory depression or impaired oxygenation in appropriate doses 2
• Caution: Avoid morphine in severe renal insufficiency; adjust dosing intervals based on renal function 6
• Side effects: Manage initial nausea and persistent constipation 2

Adjunctive benzodiazepines:

• Use lorazepam when opioids provide insufficient relief, particularly when anxiety is a co-factor 2, 6

Oxygen therapy for symptomatic relief:

• Evidence is conflicting for relieving breathlessness even in hypoxemic COPD patients 2
• Use only for symptomatic hypoxia or when subjective relief is reported 6
• Room air via nasal cannula may be as effective as supplemental oxygen for refractory dyspnea 2

For excessive secretions causing dyspnea:

• Glycopyrrolate (preferred—doesn't cross blood-brain barrier, less delirium risk) 2
• Alternatives: Scopolamine (subcutaneous or transdermal—note 12-hour onset for patches), atropine, hyoscyamine 2

Advanced/Palliative Interventions

For patients with limited life expectancy:

• Noninvasive positive-pressure ventilation (BiPAP): May temporarily improve symptoms but only in predisposed settings with trained staff 2
• Terminal sedation: Benzodiazepines or propofol as second-line if dyspnea unresolved with adequate opioid doses 2
• Palliative care consultation for refractory symptoms 6

Monitoring Response

Use six-minute walk test to measure effect of ongoing interventions 5

Critical Pitfall

There are currently no FDA-approved treatments for dyspnea per se (only for diseases causing dyspnea), and even with evidence of efficacy, the magnitude of benefit is variable—manage expectations accordingly. 2