What is the approach to a patient presenting with shortness of breath in the emergency department?

Approach to Shortness of Breath in the Emergency Department

Begin with immediate scene safety verification, followed by simultaneous assessment of responsiveness, breathing pattern, and pulse within 10 seconds, then immediately administer high-flow oxygen (15 L/min via non-rebreather mask) for patients in respiratory distress while activating emergency response if the patient is unresponsive or has absent/abnormal breathing. 1

Immediate Assessment (First 10 Seconds)

Scene Safety and Initial Evaluation

• Verify scene safety before approaching the patient to avoid becoming a second victim 1
• Check responsiveness by tapping the patient and calling out 2
• Simultaneously assess breathing pattern and circulation—do not perform these sequentially 1, 3
• Activate emergency response immediately if patient is unresponsive or has absent/abnormal breathing 1, 3

Critical Breathing Pattern Recognition

• Distinguish between three patterns: normal breathing, abnormal breathing (only gasping), and absent breathing 1, 3
• Agonal gasps are NOT normal breathing and should be treated as absent breathing 3
• If breathing is absent or only gasping with no pulse, immediately begin CPR at 100-120 compressions/minute 1, 2
• If uncertain about pulse presence after 10 seconds, begin CPR—do not delay 1, 2

Airway Management

Airway Patency Assessment

• Look for chest rise, listen for breath sounds, and feel for air movement 1
• Remove visible obstructions from the mouth, but never perform blind finger sweeps as this can push foreign bodies deeper 1
• Perform head tilt-chin lift maneuver unless cervical spine injury is suspected 1

Oxygen Therapy and Positioning

Oxygen Administration

• Administer 100% oxygen at 15 L/min via non-rebreather mask for patients in respiratory distress 1
• Pulse oximetry must be available in all locations where emergency oxygen is used 3
• Do not use supplemental oxygen indiscriminately—provide only when hypoxemia or respiratory distress is present 1

Patient Positioning Based on Clinical Presentation

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

Vital Signs and Monitoring

Essential Initial Measurements

• Record pulse rate, respiratory rate, and pulse oximetry immediately 3
• Measure blood pressure in suspected cardiac disease 3
• Record peak expiratory flow in suspected asthma 3
• Monitor oxygen saturation continuously until patient is stable 3

Targeted Interventions Based on Clinical Presentation

Specific Disease-Directed Therapy

• Assist with inhaled bronchodilators (albuterol) for acute shortness of breath with known asthma 1
• Administer epinephrine via autoinjector immediately if anaphylaxis is suspected 1
• Administer aspirin for chest pain associated with shortness of breath, as prehospital administration improves outcomes compared to delayed in-hospital administration 1
• Consider BNP or NT-proBNP measurement, with BNP >100 pg/mL or NT-proBNP >300 pg/mL suggesting heart failure as the cause 1

Bronchodilator Caveat

• Be aware that bronchodilator therapy can cause increased V/Q mismatch and reduced blood oxygen levels shortly after treatment in acutely ill patients 3

Differential Diagnosis Considerations

Most Common Causes (Account for Two-Thirds of Cases)

• Cardiac: heart failure, acute coronary syndrome, myocardial ischemia 4, 5
• Pulmonary: pneumonia, chronic obstructive pulmonary disease, asthma, interstitial lung disease 4, 5
• Other: anemia, pulmonary embolism, mental disorders 4
• Etiology is multifactorial in approximately one-third of patients 5

Resuscitation Protocols

If CPR is Required

• Push hard (at least 2 inches in adults, at least one-third of anterior-posterior chest diameter in children) and fast (100-120 compressions/minute) 2, 3
• Allow complete chest recoil after each compression 2
• Minimize interruptions in compressions 2, 3
• Single rescuer: perform 30 compressions to 2 breaths 2, 1
• Two rescuers (pediatric): perform 15 compressions to 2 breaths 3, 6
• Use AED as soon as available 2, 3
• Once advanced airway is placed, provide continuous compressions at 100-120/minute with 1 breath every 6 seconds (10 breaths/minute) 1, 3

Pediatric-Specific Considerations

• Start CPR immediately when heart rate <60 bpm with signs of poor perfusion 6, 3
• Compress at least one-third of anterior-posterior chest diameter 6
• Change compressor every 2 minutes or sooner if fatigued 3

Critical Pitfalls to Avoid

• Do not delay oxygen administration or airway management to obtain detailed history—immediate stabilization takes priority 1
• Do not perform prolonged pulse checks beyond 10 seconds 1, 2
• Avoid blind finger sweeps when managing airway obstruction 1
• Do not assume normal breathing if only gasping is present 3
• Do not interrupt compressions for prolonged periods if CPR is ongoing 3, 2

Documentation Requirements

• A written record must be made of oxygen therapy given to every patient, similar to recording all other emergency treatment, even when given without formal prescription 3