What is the immediate assessment and management for a patient presenting with acute breathlessness?

Immediate Management of Acute Breathlessness

For a patient presenting with breathlessness, immediately assess responsiveness, breathing pattern, and pulse simultaneously within 10 seconds, then measure oxygen saturation and vital signs while initiating oxygen therapy targeting 94-98% (or 88-92% if COPD/hypercapnic risk) and preparing for potential resuscitation if the patient is critically ill. 1, 2

Initial Assessment (First 60 Seconds)

Check for Critical Illness:

• Verify scene safety and check responsiveness by shouting and tapping the patient 1
• Look for absent or abnormal breathing (gasping only counts as absent breathing) and check pulse simultaneously—limit this to maximum 10 seconds 1
• If unresponsive with no normal breathing or only gasping, assume cardiac arrest and begin CPR immediately with chest compressions at 100-120/minute, depth 5-6 cm, while activating emergency response 1, 3

If Patient is Responsive:

• Measure oxygen saturation immediately using pulse oximetry—this is the "fifth vital sign" 1, 2
• Record respiratory rate, pulse rate, blood pressure, and temperature 1, 2
• Assess if patient can speak in full sentences (inability suggests severe respiratory distress) 2

Oxygen Therapy Initiation

Determine Risk Category:

For critically ill patients (unable to speak, altered mental status, severe distress):

• Start 15 L/min oxygen via reservoir mask immediately 1
• Prepare for potential intubation and call for ICU assistance 1

For patients at risk of hypercapnic respiratory failure (COPD, severe obesity, chest wall deformities, neuromuscular disease):

• Target oxygen saturation 88-92% 1, 2
• Start with 24-28% oxygen or 1-2 L/min nasal oxygen 1
• Obtain arterial blood gas urgently 1
• Critical pitfall: High-concentration oxygen in these patients worsens respiratory acidosis and increases mortality 1, 2

For all other patients:

• Target oxygen saturation 94-98% 1, 2
• Titrate oxygen to achieve target 1

Immediate Clinical Assessment

Assess for Life-Threatening Causes:

• Chest pain with breathlessness: Consider acute coronary syndrome—administer aspirin 160-325 mg (chewed) unless contraindicated 1
• Sudden ripping chest pain in hypertensive patient: Suspect acute aortic syndrome—requires immediate imaging 2
• Breathlessness with syncope/presyncope: Consider pulmonary embolism or cardiac pathology 2
• Wheezing with cutaneous manifestations (hives, lip/eye swelling) or hypotension: This is anaphylaxis—administer epinephrine 0.3 mg IM immediately 1, 2

Perform Focused Examination:

• Auscultate lungs for wheezing, crackles, or absent breath sounds 1
• Check for accessory muscle use and ability to complete sentences 1, 2
• Assess for signs of heart failure (elevated JVP, peripheral edema) 1
• Look for unilateral leg swelling suggesting DVT/PE 2

Condition-Specific Immediate Treatment

For wheezing/suspected asthma or COPD exacerbation:

• Administer inhaled bronchodilators (albuterol/salbutamol) immediately via nebulizer or MDI with spacer 1, 2
• Give systemic corticosteroids (oral or IV) 1
• Administer antibiotics if evidence of infection 1

For suspected acute hypercapnic respiratory failure:

• Obtain arterial blood gas before adjusting oxygen 1
• If pH <7.35 with elevated CO2, prepare for non-invasive ventilation (NIV) 1
• Ensure NIV-experienced clinician involvement 1
• Have ICU consultation ready if patient deteriorates 1

Monitoring and Escalation

Use Track-and-Trigger System:

• Apply National Early Warning Score (NEWS) or equivalent physiological scoring 1, 2
• For COPD/hypercapnic risk patients, use the 2017 NEWS chart that awards points if oxygen saturation is below OR above target range 1

Escalate Care If:

• Oxygen saturation drops ≥3% suddenly—this requires immediate reassessment 2
• Patient cannot maintain target saturations despite oxygen therapy 2
• Signs of impending respiratory failure develop (altered mental status, inability to speak, accessory muscle use) 2
• Patient triggers high-risk criteria on NEWS 2

Critical Pitfalls to Avoid

• Do not assume normal pulse oximetry rules out serious pathology—in carbon monoxide poisoning, pulse oximetry will be falsely normal 2
• Do not delay CPR if uncertain about pulse after 10 seconds—start compressions if in doubt 1, 3
• Do not overlook cardiac causes in women—they often present with atypical symptoms 2
• Do not fail to recognize atypical presentations in elderly—confusion, delirium, or falls may be the only manifestation of breathlessness 2
• Do not administer high-flow oxygen to COPD patients without blood gas guidance—this can precipitate respiratory failure 1, 2
• Do not delay obtaining arterial blood gas in patients at risk of hypercapnic respiratory failure 1

Immediate Diagnostic Workup

While stabilizing the patient:

• Obtain chest X-ray as initial imaging for all patients with unexplained breathlessness 2
• Perform ECG if cardiac cause suspected 1, 2
• Check arterial blood gas for patients at risk of hypercapnic respiratory failure 1
• Consider CT angiography if pulmonary embolism suspected 2