Dyspnea

Key considerations: Pulmonary embolism, Tension pneumothorax, Acute heart failure / pulmonary edema

Cannot miss

history: Acute vs chronic, progressive vs sudden onset; Orthopnea, PND (heart failure); Wheezing, cough, sputum (asthma, COPD, pneumonia); Pleuritic pain (PE, pneumonia, pneumothorax); Fever, chills (infection); Leg swelling, recent travel/immobilization (DVT/PE); Allergen exposure, new medications; exam: Respiratory rate, SpO2, work of breathing; Lung: wheezes, crackles, absent breath sounds, rhonchi; Cardiac: JVD, S3, murmurs, muffled heart sounds (tamponade); Extremities: edema, calf tenderness (DVT); Skin: urticaria, angioedema (anaphylaxis); Accessory muscle use, tripod positioning; labs: CBC: WBC (infection), Hgb (anemia); BMP: BUN/Cr (renal failure causing fluid overload); BNP/NT-proBNP: heart failure; D-dimer: PE if low pretest probability; ABG/VBG: respiratory failure assessment; Procalcitonin if pneumonia vs non-infectious; imaging: CXR: pneumonia, pneumothorax, pulmonary edema, pleural effusion; CT angiography chest: PE; CT chest: interstitial lung disease, masses; Lung ultrasound: B-lines, effusion, consolidation, pneumothorax; bedside: Point-of-care ultrasound: lung (B-lines, sliding, effusion), cardiac (EF, RV, pericardial effusion); 12-lead ECG: RV strain (PE), ischemia; Peak flow if asthma/COPD

immediate: Supplemental O2 to target SpO2 92–96% (88–92% in COPD); IV access, cardiac monitor; Assess airway — intubate if impending respiratory failure; Needle decompression if tension pneumothorax; general: Identify and treat underlying cause; Reassess frequently — dyspnea can deteriorate rapidly; Positioning: upright for pulmonary edema, supine for hypotension; specific: diagnosis: Heart Failure; steps: Nitroglycerin drip + furosemide IV; BiPAP if respiratory distress; Reduce preload: nitrates, diuretics; diagnosis: Pneumonia; steps: Antibiotics per guidelines — community vs hospital acquired; Supplemental O2; Fluid resuscitation if septic; diagnosis: Pneumothorax; steps: Small (<2cm): observation and O2; Large or symptomatic: chest tube; Tension: immediate needle decompression at 2nd ICS MCL

admit: Hypoxia requiring supplemental O2; Respiratory failure or impending failure; New diagnosis of PE, pneumothorax requiring intervention; Heart failure requiring IV diuretics; Pneumonia with CURB-65 ≥2; discharge: Asthma with good response to treatment and PEF >70%; Anxiety/hyperventilation with normal workup; Stable COPD with return to baseline; Follow-up arranged within 48 hours; consults: Pulmonology: refractory asthma/COPD, ILD, complex pleural disease; Cardiology: new heart failure, valvular disease; Surgery: chest tube, surgical airway

The most important question in acute dyspnea: Is this cardiac or pulmonary? BNP + lung ultrasound can differentiate
Tension pneumothorax is a clinical diagnosis — do NOT wait for CXR if suspected
BiPAP in acute pulmonary edema reduces intubation rates — use early
Silent chest in asthma = severe bronchospasm — absence of wheezing is ominous
D-dimer is only useful to RULE OUT PE when pretest probability is low (Wells ≤4)

ATS/ERS Dyspnea Guidelines, GOLD COPD Guidelines 2024, GINA Asthma Guidelines 2024. Last reviewed: 2024-11-01