Shortness of breath resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Steven Bellm, M.D. [2]

Shortness of breath resident survival guide Microchapters
Overview
Definitions
Causes
FIRE
Diagnosis
Treatment
Do's
Dont's

Overview

Dyspnea is a symptom, it must generally be distinguished from signs that clinicians typically invoke as evidence of respiratory distress, such as tachypnea, use of accessory muscles, and intercostal retractions.[1]

Respiratory discomfort may arise from many clinical conditions, but also may be a manifestation of poor cardiovascular fitness in our increasingly sedentary population. Diagnosis and treatment of the underlying cause of dyspnea is the preferred and most direct approach to improve this symptom, but there are many patients for whom the cause is unclear or for whom dyspnea persists despite optimal treatment.[2]

Definitions

A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.[3]
A respiratory rate greater than normal.
Increased minute ventilation to meet metabolic requirements.
It is the result of an increased frequency of breathing, an increased tidal volume, or a combination of both. It causes an excess intake of oxygen and the blowing off of carbon dioxide.
Dyspnea caused by physical effort or exertion.
Dyspnea caused by a recumbent position.
Dyspnea that starts suddenly while reclining at night.
Dyspnea that starts in an upright position.
Dyspnea that starts in one lateral decubitus position as opposed to the other.[4]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

  • Life-threatening causes of the upper airway
  • Life-threatening pulmonary causes
  • Life-threatening cardiac causes
  • Life-threatening neurologic causes
  • Life-threatening toxic and metabolic causes

Miscellaneous Causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.[5]

 
 
 
 
 
Dyspnea
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Initial evaluation:

❑   Check Vital Signs:

❑  Heart rate
❑  Respiratory rate
❑  Blood pressure

❑  SaO2
❑  ECG/cardiac monitor
❑  ± Continuous waveform capnography
❑   Danger signs: Depressed mental status, cyanosis, inability to maintain respiratory effort, use of accessory muscles, abnormal chest movement
❑  Action items

❑   Supplement oxygen
❑   IV access and pulse oximetry
❑  Lab measurements:
❑  ABG, A-a gradient
❑  WBC, Hgb, Hct, Platelets, Smear
❑  BUN, Cr, K, Mg, Phos
❑  Glucose
❑  D-Dimer, NT-proBNP, Troponin
❑  Keep airway managment equipment ready
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signs for rapidly reversible causes?
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Tension pneumothorax:

❑  Signs:

❑  Chest pain
❑  Hypotension
❑  Tracheal deviation
❑  Raised jugular venous pressure
❑  Quieter breath sounds/hyperresonant percussion
❑  Tachycardia/tachypnea

❑  Treatment:

❑  Immediate chest decompression by needle or tube thoracostomy
Upper airway foreign body aspieation:

❑  Signs:

❑  Coughing, cyanosis

❑  Treatment:

❑  Bronchoscopy/Laryngoscopy
Pericardial tamponade:

❑  Signs(Becks's triade):

❑  Hypotension
❑  Muffled heart sounds
❑  Jugular-venous distension

❑  Treatment:

❑  Pericardiocentesis
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ability to maintain own airway?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
Action items:

❑  Try to assess ventilation
❑  Check breath sounds

❑  Endotracheal intubation/cricothyrotomy and mechanical ventilation
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chest x-ray
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess breath sounds, obtain history and physical exam
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to Complete Diagnostic Approach
 
 
 
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

 
 
 
 
 
 
 
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Treatment

shown

hidden

Do's

Dont's

References

  1. ↑ Campbell ML (2008). "Psychometric testing of a respiratory distress observation scale". J Palliat Med. 11 (1): 44–50. doi:10.1089/jpm.2007.0090. PMID 18370892.
  2. ↑ Desbiens NA, Mueller-Rizner N, Connors AF, Wenger NS (1997). "The relationship of nausea and dyspnea to pain in seriously ill patients". Pain. 71 (2): 149–56. PMID 9211476.
  3. ↑ "Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society". Am J Respir Crit Care Med. 159 (1): 321–40. 1999. doi:10.1164/ajrccm.159.1.ats898. PMID 9872857.
  4. ↑ Marx, John (2014). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455706051.
  5. ↑ Marx, John (2014). Rosen's emergency medicine : concepts and clinical practice. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455706051.
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