II. Definition: Acute Dyspnea

  1. Subjective difficult or distressed breathing <1 month

III. Causes

IV. Symptoms

  1. Shortness of Breath
  2. Chest tightness

V. Signs

  1. Patient breaks up sentence to pause for breath
  2. Tachypnea
  3. Increased respiratory excursions
  4. Nasal flaring
  5. Cyanosis
  6. Accessory muscle use
    1. Chest and abdominal muscle use
    2. Neck muscle use (Scalene, Sternocleidomastoid)

VI. History

VII. Exam

  1. Nose and sinus exam
  2. Fluid status exam
    1. Jugular Venous Distention
    2. Hepatojugular Reflex
    3. Peripheral Edema
  3. Peripheral Vascular Exam
    1. Decreased pulses or bruits
  4. Respiratory Exam
    1. Increased AP Chest diameter
    2. Wheezing
    3. Rales
    4. Cyanosis
    5. Clubbing
    6. Accessory muscle use (Neck, chest, Abdomen)
    7. Speaking in phrases to catch breath
  5. Cardiac Auscultation
    1. Tachycardia
    2. S3 Gallup Rhythm
    3. Cardiac Murmur
  6. Psychomotor exam
    1. Anxiety

VIII. Evaluation: Phone Triage - Indications for Emergency Room Evaluation

  1. Adults
    1. Severe Dyspnea
    2. New onset of Dyspnea at rest
    3. Sudden Chest Pain onset associated with Dyspnea
  2. Children
    1. Dyspnea in a child under age 3 months
    2. Sudden onset Dyspnea
    3. Temperature over 102 F
    4. Lethargy
    5. Pharyngitis with Dyspnea
    6. Croup-type cough with Dyspnea
  3. References
    1. Zoorob (2003) Am Fam Physician 68(9):1803-10

IX. Evaluation: Acute Dyspnea

  1. Also see Chronic Dyspnea
  2. Immediate ABC Management
    1. Emergency Airway Management
    2. Emergency Breathing Management
    3. Emergency Circulation Management
  3. Obtain initial Vital Signs
    1. Temperature, Blood Pressure, and Pulse
    2. Respiratory Rate and Oxygen Saturation
  4. Immediately triage unstable patients
    1. Hypotension
    2. Altered Level of Consciousness
    3. Hypoxia (decreased Oxygen Saturation)
    4. Arrhythmia
    5. Stridor or other signs of upper airway obstruction
    6. Unilateral breath sounds or other Pneumothorax signs
    7. Respiratory Rate >40 breaths per minute
    8. Accessory muscle use with retractions
    9. Cyanosis
  5. Initial management of acute distress
    1. Obtain Intravenous Access
    2. Administer High Flow Oxygen
    3. Evaluate and treat Hypoxia if present
      1. Consider Pulmonary Embolism Diagnosis
  6. Initiate disease specific management
    1. See Emergency Management of Asthma Exacerbation
    2. See COPD Exacerbation Management
    3. See Acute Pulmonary Edema Management
    4. See Tension Pneumothorax and Needle Thoracentesis

X. Imaging

  1. Chest XRay
    1. Indicated in all cases
    2. Identifies primary pulmonary causes of Dyspnea
  2. Spiral CT or Ventilation-Perfusion Scan
    1. Indicated for Hypoxia with normal CXR, Spirometry
  3. Bedside Ultrasound
    1. See Lichtenstein Dyspnea Evaluation by Ultrasound Protocol (Blue Protocol)
    2. See Volpicelli Dyspnea Evaluation with Ultrasound Protocol
  4. Echocardiogram
    1. Indicated for suspected cardiogenic cause

XI. Labs

  1. Initial (as directed by clinical findings)
    1. Hemoglobin or Hematocrit
    2. Thyroid Stimulating Hormone (TSH)
    3. Electrocardiogram (EKG)
    4. Arterial Blood Gas
    5. B-Type Natriuretic Peptide (BNP)
      1. BNP use expedites ER evaluation and lowers cost
        1. CHF most likely Dyspnea cause when BNP >500 pg/ml
        2. CHF unlikely Dyspnea cause when BNP <100 pg/ml
        3. Mueller (2004) N Engl J Med 350:647-54
      2. BNP with Chest XRay identifies CHF as Dyspnea cause
        1. Knudson (2004) Am J Med 116:363-8
  2. Second line tests (when stable)
    1. Pulmonary Function Tests (Spirometry)
    2. Exercise Treadmill Testing with Oxygen Saturation

XII. References

  1. Braithwaite in Marx (2002) Rosen's Emergency, p. 155-62
  2. Degowin (1987) Diagnostic Exam, p. 281-2
  3. Fangman in Noble (2001) Primary Care, p. 175-8
  4. Marini (1987) Respiratory Medicine, p. 40-41
  5. Stulbarg in Murray (2000) Respiratory Med, p. 541-52
  6. Zoorob (2003) Am Fam Physician 68(9):1803-10

Images: Related links to external sites (from Google)

Ontology: Dyspnea (C0013404)

Definition (NCI) An uncomfortable sensation of difficulty breathing. It may present as an acute or chronic sign of an underlying respiratory or heart disorder.
Definition (NCI) A disorder characterized by an uncomfortable sensation of difficulty breathing.
Definition (MSH) Difficult or labored breathing.
Definition (PSY) Difficulty in breathing which may or may not have an organic cause.
Definition (CSP) labored or difficult breathing associated with a variety of disorders, indicating inadequate ventilation or low blood oxygen or a subjective experience of breathing discomfort.
Definition (NCI) Difficult, painful breathing or shortness of breath.
Concepts Sign or Symptom (T184)
MSH D004417
ICD9 786.05
ICD10 R06.0 , R06.02, R06.00
SnomedCT 308149007, 207059009, 207057006, 158371003, 161945003, 139201002, 139207003, 139200001, 161946002, 158379001, 161937008, 139192008, 49233005, 207062007, 161951008, 267036007, 230145002, 248552009
English Dyspneas, BREATH SHORTNESS, BREATHING DIFFICULT, BREATHLESSNESS, DYSPNEA, DYSPNOEA, Dyspnea, NOS, SHORTNESS OF BREATH, SOB, SOB (SHORTNESS OF BREATH), Dyspnoea, NOS, Breathlessness NOS, Dyspnea, Shortness of breath dyspnea, [D]Breathlessness (context-dependent category), [D]Dyspnea (context-dependent category), [D]Shortness of breath (context-dependent category), Dyspnea NOS, [D]Dyspnea, [D]Dyspnoea, [D]Shortness of breath, Respiratory difficulties, [D]Breathlessness, shortness of breath, dyspnea, difficulty breathing, SOB (shortness of breath), difficulty breathing (symptom), shortness of breath (symptom), s.o.b., sob, [D]Dyspnoea (situation), Dyspnoea (finding), Breathlessness NOS (finding), [D]Shortness of breath (situation), (Symptom: [SOB] or [breathlessness] or [dyspnoea]) or (breathlessness) (finding), [D]Breathlessness (situation), Short of breath, Breath shortness, Breathing difficult, Dyspnoea NOS, Dyspnoeas, RESPIRATORY DIFFICULTY, [D]Dyspnea (situation), DIFFICULTY BREATHING, BREATHING DIFFICULTIES, Dyspnea [Disease/Finding], Breath Shortness, Shortness of Breath, Breath Shortnesses, Shortness (of);breath, Difficulty;breathing, breathing difficulties, breathing difficulty, breathless, difficult breathing, breathing shortness, respiratory difficulty, breath shortness, shortness of breath (SOB), Dyspnea, unspecified, Breathlessness, Shortness of breath, Difficulty breathing, Respiration difficult, Winded, Dyspnoea, DIB - Difficulty in breathing, SOB - Shortness of breath, Breathless, Difficulty breathing (finding), Dyspnea (finding), Winded (finding), Shortness of breath/dyspnoea, breath; shortness of breath, breathlessness, shortness of breath; breath, Breathlessness symptom, (Symptom: [SOB] or [breathlessness] or [dyspnea]) or (breathlessness), (Symptom: [SOB] or [breathlessness] or [dyspnoea]) or (breathlessness), Difficulty breathing [Ambiguous], Dyspnea (finding) [Ambiguous], Dyspnea - symptom, Dyspnoea - symptom, Short of breath symptom, Shortness of breath symptom, tightness of breath, dyspnoea
French DYSPNEE, Difficultés à respirer, Difficulté respiratoire, Essoufflement, Essouf, Respiration difficile, Dyspnée SAI, Essouflé(e), DIFFICULTE RESPIRATOIRE, SOUFFLE COURT, Souffle court/dyspnee, Dyspnées, Dyspnée
Portuguese DISPNEIA, Dispneia NE, Dispneico, Falta de ar, Dificuldade em respirar, Dificuldade da respiração, DIFICULDADE RESPIRATORIA, Dispneia/fadiga respiratoria, RESPIRACAO DE BAIXA AMPLITUDE, Falta de Ar, Dispneias, Dispneia, Dispnéia
Spanish DISNEA, Respiración dificil, DR, DR (dificultad respiratoria), Disnea NEOM, Respiración difícil, Dificultad al respirar, Dificultad para respirar, Falta de aliento, Dificultad de la respiración, [D]falta de aire (categoría dependiente del contexto), [D]disnea, [D]respiración agitada (categoría dependiente del contexto), [D]falta de aliento, Dyspnoea, Difficulty breathing, (Symptom: [SOB] or [breathlessness] or [dyspnoea]) or (breathlessness), Dyspnea, (Symptom: [SOB] or [breathlessness] or [dyspnea]) or (breathlessness), Shortness of breath symptom, [D]Dyspnea, [D]Breathlessness, Short of breath symptom, [D]Dyspnoea, Dyspnea - symptom, Dyspnoea - symptom, [D]Shortness of breath, Difficulty breathing [Ambiguous], Breathlessness, Breathlessness symptom, Fatiga respiratoria, disnea, RESPIRACION ACORTADA, RESPIRACION, DIFICULTAD, [D]falta de aire, [D]disnea (situación), [D]falta de aire (situación), [D]respiración agitada, [D]respiración agitada (situación), Breathlessness NOS, [D]disnea (categoría dependiente del contexto), [D]falta de aliento (categoría dependiente del contexto), dificultad para respirar (hallazgo), dificultad para respirar, dificultad respiratoria, disnea (concepto no activo), disnea (hallazgo), disnea, falta de aire, falta de aliento, SAI (hallazgo), falta de aliento, SAI, respiración dificultosa, respiración difícil (hallazgo), respiración difícil, sin aliento (hallazgo), sin aliento, Disneas, Disnea
German DYSPNOE, Atemlosigkeit, Schwierigkeiten beim Atmen, SOB, Kurzatmigkeit, Atmung erschwert, kurzatmig, SOB (Kurzatmigkeit), Dyspnoe NNB, ATMUNG ERSCHWERT, KURZATMIGKEIT, Kurzatmigkeit/Dyspnoe, Dyspnoen, Atemnot, Dyspnoe
Italian Dispnee, Respirazione difficoltosa, Dispnea NAS, Difficoltà nella respirazione, Dispnea e anomalie respiratorie, Respiro affannoso dispnea, Dispnea
Dutch moeilijk ademen, kortademigheid, kortademigheid NAO, Dyspnoe/benauwdheid, Kortademigheid, adem; kortademigheid, kortademigheid; adem, dyspneu, dyspnoea, Ademnood, Dyspneu, Dyspnoe, Dyspnoea
Japanese 呼吸困難NOS, イキギレ, コキュウコンナン, コキュウコンナンNOS, 呼吸窮迫, 呼吸困難, 息切れ
Swedish Andnöd, ANDNOD/DYSPNE
Czech dyspnoe, dušnost, Pocit dechové nedostatečnosti, Dušnosti, Dyspnoe, Dušnost, Ztížené dýchání, Pocit zkráceného dechu, Dýchání ztížené, Dyspnoe NOS, Dýchavičnost
Finnish Hengenahdistus, HENGENAHDISTUS/DYSPNEA
Russian ODYSHKA, ОДЫШКА
Danish Andenod/dyspno
Norwegian TUNGPUSTET/KORTPUSTET/DYSPNE
Hungarian nehezlegzes/dyspnoe, Légszomj, Fulladás, Nehézlégzés, Légszomj (fulladás), Kilégzési rövidség, Légzésrövidülés, Nehézlégzések, Légzés nehezített, Dyspnoe k.m.n., Nehéz légzés
Korean 호흡곤란
Croatian DISPNEJA
Basque ARNASBEHARRA, DISNEA
Hebrew kotzer neshima
Polish Duszność

Ontology: Orthopnea (C0085619)

Concepts Sign or Symptom (T184)
ICD9 786.02
ICD10 R06.01
SnomedCT 207051007, 62744007, 161942000, 139197002, 158373000
English ORTHOPNEA, Breathless - lying flat, Must sit up to breath, [D]Orthopnea (context-dependent category), [D]Orthopnea, [D]Orthopnoea, Orthopnea, (Breathless - lying flat) or (orthopnoea symptom) (finding), [D]Orthopnoea (situation), [D]Orthopnea (situation), breath sit up, Orthopnoea, Breathlessness lying flat, Orthopnea (finding), orthopnea, (Breathless - lying flat) or (orthopnea symptom), (Breathless - lying flat) or (orthopnoea symptom), Orthopnea symptom, Orthopnoea symptom, orthopnoea
Italian Ortopnea
Japanese 起坐呼吸, キザコキュウ
Spanish [D]ortopnea (categoría dependiente del contexto), (Breathless - lying flat) or (orthopnoea symptom), Breathless - lying flat, Orthopnea symptom, (Breathless - lying flat) or (orthopnea symptom), [D]Orthopnoea, Orthopnoea symptom, [D]Orthopnea, [D]ortopnea, [D]ortopnea (situación), ortopnea (hallazgo), ortopnea, Ortopnea
Czech Ortopnoe
Hungarian Orthopnoe
Portuguese Ortopneia
Dutch orthopnoea
French Orthopnée
German Orthopnoe