What is the initial management for a patient presenting to the ER with shortness of breath?

Initial Management of Shortness of Breath in the Emergency Department

The initial management of a patient presenting to the ER with shortness of breath requires immediate assessment of airway patency, breathing adequacy, and circulation status, followed by rapid stabilization with supplemental oxygen, positioning, and targeted interventions based on the underlying cause. 1

Immediate Assessment and Stabilization

Scene Safety and Initial Approach

• Verify scene safety before approaching the patient to avoid becoming a second victim 2
• Simultaneously assess responsiveness, breathing pattern, and circulation within the first 10 seconds 1, 2
• Activate the emergency response system immediately if the patient is unresponsive or has absent/abnormal breathing 1

Airway Assessment

• Check for airway patency by looking for chest rise, listening for breath sounds, and feeling for air movement 1
• Look for signs of airway obstruction including stridor, inability to speak, use of accessory muscles, or paradoxical chest movements 3, 4
• Remove any visible obstruction from the mouth, but avoid blind finger sweeps 1, 5
• If the airway is not patent, perform head tilt-chin lift maneuver (unless cervical spine injury is suspected) 1

Breathing Assessment

• Distinguish between normal breathing, abnormal breathing (only gasping), and absent breathing within 10 seconds 1, 2
• If breathing is absent or only gasping is present with no pulse, immediately begin CPR with chest compressions at 100-120 compressions per minute 2
• If breathing is present but inadequate (respiratory distress without cardiac arrest), proceed to oxygen therapy and further evaluation 1

Oxygen Therapy and Positioning

Supplemental Oxygen Administration

• Administer 100% oxygen at 15 L/min via non-rebreather mask for patients in respiratory distress 2
• Begin bag-mask ventilation if respiratory effort is inadequate to maintain oxygenation 2, 6
• No evidence supports routine supplemental oxygen for all patients with shortness of breath, but it should be provided when hypoxemia or respiratory distress is present 1

Patient Positioning

• Place the patient in a supine position if shock is suspected, with consideration for passive leg raising at 30-60 degrees for transient benefit (lasting approximately 7 minutes) 1
• Use the lateral recumbent (recovery) position for unresponsive patients who are breathing normally, as this reduces the need for advanced airway management compared to supine positioning 1
• Maintain upright positioning for patients with suspected cardiogenic pulmonary edema or severe respiratory distress who are alert and able to maintain their airway 1

Targeted Interventions Based on Clinical Presentation

For Suspected Asthma/Bronchospasm

• Assist with administration of inhaled bronchodilators (albuterol) for patients with acute shortness of breath and known asthma 1
• Administer albuterol 2.5 mg via nebulizer over 5-15 minutes, which can be repeated as needed 7
• Consider adding ipratropium bromide, which can be mixed with albuterol in the nebulizer if used within one hour 8

For Suspected Anaphylaxis

• Administer epinephrine via autoinjector immediately if anaphylaxis is suspected 1
• A second dose of epinephrine may be beneficial when the first dose fails to improve symptoms 1

For Suspected Acute Coronary Syndrome

• Administer aspirin for chest pain associated with shortness of breath, as early (prehospital) administration improves outcomes compared to delayed (in-hospital) administration 1

For Suspected Heart Failure

• Consider BNP or NT-proBNP measurement to aid in diagnosis, with BNP >100 pg/mL or NT-proBNP >300 pg/mL suggesting heart failure as the cause of dyspnea 1
• Age-adjusted cutoffs improve specificity: NT-proBNP >450 pg/mL for age ≥75 years 1

Advanced Airway Management

Indications for Advanced Airway

• Perform endotracheal intubation if ventilation is required for prolonged periods or if bag-mask ventilation is inadequate 6
• Anticipate each intubation as potentially difficult and have backup plans ready 6
• Emergency cricothyroidotomy should be performed immediately in "cannot intubate, cannot oxygenate" situations to prevent hypoxic brain damage 9

Ventilation Strategy

• Once an advanced airway is placed, provide continuous compressions at 100-120/minute with 1 breath every 6 seconds (10 breaths/minute) if CPR is ongoing 5
• Use mechanical ventilators for longer-term ventilatory support to minimize work of breathing 6

Critical Pitfalls to Avoid

• Do not delay oxygen administration or airway management to obtain a detailed history, as immediate stabilization takes priority 2
• Do not perform prolonged pulse checks; if uncertain after 10 seconds, begin CPR 2
• Do not use supplemental oxygen indiscriminately without clinical indication, as no evidence supports routine use for all patients with shortness of breath 1
• Avoid blind finger sweeps when managing airway obstruction, as this can push foreign bodies deeper 1, 5
• Do not delay emergency cricothyroidotomy in "cannot intubate, cannot oxygenate" situations, as rapid action is essential to prevent death 9
• When using face masks for nebulized medications, ensure proper fit to avoid leakage that could cause eye complications including blurred vision or precipitation of narrow-angle glaucoma 8