💡Dyspnea is the perception of an inability to breathe comfortably

❗️An unremarkable pulmonary and cardiac examination does not rule out significant disease. As examples, the sensitivity and specificity of the pulmonary examination are limited for making the diagnosis of pneumonia or ADHF.

▪️The most common diagnoses among older adult patients presenting to an ED with a complaint of acute shortness of breath and manifesting signs of respiratory distress (eg, RR > 25,[SpO2] < 93 percent) are:
• ADHF,
• pneumonia,
• (COPD) and asthma.
• pulmonary embolism (PE)

▪️Common life-threatening causes of acute dyspnea:
• Acute coronary syndrome
• Acute heart failure
• Arrhythmia
• Pericardial tamponade
• Pulmonary embolism (PE)
• Pneumonia or other infection
• Chronic obstructive pulmonary disease (COPD) exacerbation
• Asthma
• Acute airway obstruction, angioedema, and anaphylaxis
• Poisoning (eg, carbon monoxide)
• Trauma (eg, pneumothorax, hemothorax)

‼️Some potential pitfalls in the approach:

• Over-reliance upon a single finding (physical examination or test result) to establish a diagnosis.

• Failure to consider carbon monoxide poisoning, methemoglobinemia, or PE.

• Misinterpreting tachypnea, which may not represent a respiratory abnormality and may reflect nonpulmonary disease (eg, metabolic acidosis or impending herniation of the brainstem)

• In a patient with danger signs, who appears clinically ill, or is hypoxic (pulse oxygen saturation [SpO2] < 90 percent).

▪️Clinical danger signs(imminent respiratory arrest):
• Depressed mental status, which can occur with severe hypoxia or hypercarbia
• Inability to maintain respiratory effort (bradypnea, poor inspiratory effort, or agonal respirations)
• Cyanosis, which is uncommon and indicates severe hypoxia or methemoglobinemia

❗️Signs suggestive of severe respiratory distress:
- Retractions and the use of accessory muscles
- Significant tachypnea
- Appearing anxious; sitting bolt upright or in a tripod position
- Audible stridor or wheezing
- Brief, fragmented speech
- Inability to lie supine
- Profound diaphoresis; dusky skin
- Agitation or other altered mental status

▪️Provide supplemental oxygen

▫️Nasal cannula or face mask(management)

▫️High-flow nasal cannula (HFNC): for severe nonhypercapnic hypoxemic respiratory failure/ COVID-19

▫️NIV: for ADHF or a COPD exacerbation

▫️Intubation: aggressively when ventilatory support is needed and NIV is not expected to improve outcomes, such as for acute exacerbations of asthma and diseases that do not respond rapidly to medical therapy (eg, pneumonia and acute respiratory distress syndrome [ARDS]).

▪️In most ED patient , we obtain:
- CXR (portable)
- ECG
- Bedside ultrasound (if available) of the lungs and heart
- CBC and Serum chemistries(Na, Cl, K, Ca, BUN, Cr, BS), VBG.
(looking for infection, anemia, metabolic acidosis, hyperglycemia, and kidney failure and DKA).
*some references suggest checking the TSH also.

☝🏻Chest CT
it is most useful in dyspneic ED patients with trauma or concern for PE and when plain chest radiograph is inconclusive.


▪️Patients with inadequate respiratory effort
due to respiratory fatigue (eg, asthma, COPD, pneumonia) or the underlying disease process (eg, neuromuscular disease). also occurs in sepsis, stroke, etc.

▫️Identifying and monitoring hypercapnic respiratory failure: VBG, Capnography (ie, end-tidal CO2 [EtCO2]).
* The EtCO2 may be falsely low due to dilution in high-flow open systems (eg, nonrebreather masks, CPAP.