• Clinical science
  • Physician

Dyspnea

Summary

Dyspnea, or shortness of breath, is a commonly reported symptom in acute care and outpatient settings. Causes of dyspnea include pulmonary (e.g., pneumonia, asthma exacerbation), cardiac (e.g., acute coronary syndrome, congestive heart failure), toxic-metabolic (e.g., metabolic acidosis, medications), and upper airway (e.g., epiglottitis, foreign body) pathologies. On initial presentation, it is important to immediately evaluate the patient for any urgent or life-threatening causes of dyspnea with patient history, physical examination, and diagnostic testing. Once immediately life-threatening causes are ruled out, a more detailed patient history should be obtained and further testing should be done to narrow the differential diagnoses.

Approach

Approach to management

  1. ABCDE survey
  2. Establish IV access, cardiac and pulse oximetry monitoring.
  3. Start supplemental oxygen as needed.
  4. Assess the need for ventilation support and airway management.
  5. Stabilize cardiovascular function (e.g., IV fluid resuscitation).
  6. Perform focused history, examination, and diagnostics to rule out life-threatening reversible causes (see “Diagnostics” below).
  7. Once life-threatening causes have been ruled out:
  8. Treat the underlying cause.

Red flags for dyspnea

Immediately life-threatening causes

Diagnostics

The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can help to diagnose or rule out possible etiologies in patients with acute dyspnea.

Initial workup [1]

Laboratory studies

Imaging

  • ECG
  • Chest x-ray
  • CT chest with IV contrast (PE protocol)
  • TTE
  • FAST

Further diagnostics to consider

  • Respiratory viral panel
  • Blood and sputum cultures
  • Negative inspiratory flow
  • Peak flow and PFTs
  • X-ray of ribs
  • CT brain without IV contrast
  • Lumbar puncture
  • Serum salicylate level
  • TSH and free T4
  • CT neck with IV contrast

Pulmonary causes

Clinical features Diagnostic findings Acute management
Pneumonia [2]
Asthma exacerbation [3]
  • See the acute management checklist for asthma exacerbation.
Tension pneumothorax [4][5]
Spontaneous pneumothorax [6][4][7]
  • Sudden, sharp unilateral chest pain
  • Acute dyspnea
  • Hypoxemia
  • Hyperresonance, decreased breath sounds on affected side
  • Crepitus
  • History of lung disease or trauma
Pulmonary embolism [8]
Acute chest syndrome [9][10]
ARDS [11][12]
  • ABG: ↓ PaO2, A-a gradient, P/F ratio < 300 mm Hg
  • CXR: bilateral patchy diffuse or homogeneous lung infiltrates
  • TTE: normal systolic function

Cardiac causes

Clinical features Diagnostic findings Acute management
Acute coronary syndrome [13][14]
  • Heavy, dull, pressure/squeezing sensation
  • Substernal pain with radiation to left shoulder
  • Nausea, vomiting
  • Diaphoresis, anxiety
  • Dizziness, lightheadedness, syncope
  • Pain may improve with nitroglycerin.
  • ECG: nonspecific changes, ST-segment elevation/depression, T-wave inversions, Q waves
  • Increased or normal troponin
  • TTE: hypokinesis, regional wall motion abnormalities
Cardiac tamponade [15]
  • ECG: low voltage, electrical alternans
  • CXR: enlarged cardiac silhouette
  • TTE: circumferential fluid layer, collapsible chambers , high EF, dilated IVC
    • Inspiration: Both ventricular and atrial septa move sharply to the left.
    • Expiration: Both ventricular and atrial septa move sharply to the right.
Heart failure exacerbation [16][17][18][19]
Atrial fibrillation with RVR [20][21]
  • Dyspnea
  • Palpitations
  • Dizziness
  • Hypotension, syncope
Acute mitral regurgitation [22]

Upper airway causes

Clinical features Diagnostic findings Acute management
Angioedema [23][24]
Foreign body aspiration [25]
  • X-ray chest: radio-opacity in the trachea or bronchi, atelectasis
  • CT chest : direct identification of the foreign body
  • Rigid or flexible bronchoscopy: visualization of the foreign body
Epiglottitis [26][27]
Deep neck infection [28]

Toxic-metabolic and other causes

Clinical features Diagnostic findings Acute management

Salicylate toxicity [29][30]

DKA [31][32]
CO toxicity [33][34]
  • Headache, dizziness, confusion, loss of consciousness
  • Nausea, vomiting
  • Shortness of breath, tachypnea
  • Chest pain, tachycardia, hypotension
  • “Cherry red” skin
  • Hypoxia
  • Clinical diagnosis: history of exposure, typical symptoms, and COHb
  • CXR: usually normal
  • ABG: ↓ PaO2, ↑ Serum COHb (nonsmokers > 3–4%, smokers > 10%)
Anemia [35][36]
  • Normal or ↓ Hb

Anything that can cause metabolic acidosis (e.g., DKA, lactic acidosis, salicylate toxicity) can also cause acute dyspnea.

Differential diagnoses

System Differential Diagnoses [37][38][39][40]
Cardiac
Pulmonary
Gastrointestinal
Musculoskeletal
Neurologic
Endocrine
Psychogenic
Hematologic
Upper airway
Reproductive
Renal

The differential diagnoses listed here are not exhaustive.

  • 1. DeVos E, Jacobson L. Approach to Adult Patients with Acute Dyspnea. Emerg Med Clin North Am. 2016; 34(1): pp. 129–149. doi: 10.1016/j.emc.2015.08.008.
  • 2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007; 44(Supplement_2): pp. S27–S72. doi: 10.1086/511159.
  • 3. Camargo CA, Rachelefsky G, Schatz M. Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations. Proc Am Thorac Soc. 2009; 6(4): pp. 357–366. doi: 10.1513/pats.p09st2.
  • 4. Leech C, Porter K, Steyn R, et al. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. Trauma. 2016; 19(1): pp. 54–62. doi: 10.1177/1460408616664553.
  • 5. Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. 2004; 22(1): pp. 8–16. doi: 10.1136/emj.2003.010421.
  • 6. Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest. 2001; 119(2): pp. 590–602. doi: 10.1378/chest.119.2.590.
  • 7. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65(Suppl 2): pp. ii18–ii31. doi: 10.1136/thx.2010.136986.
  • 8. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016; 149(2): pp. 315–352. doi: 10.1016/j.chest.2015.11.026.
  • 9. Al-Salem A. The Acute Chest Syndrome in Sickle Cell Anemia. Springer; 2015.
  • 10. Friend A, Girzadas D. Acute Chest Syndrome. https://www.ncbi.nlm.nih.gov/books/NBK441872/. Updated January 1, 2019. Accessed November 27, 2019.
  • 11. ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012; 307(23): pp. 2526–2533. url: https://jamanetwork.com/journals/jama/article-abstract/1160659.
  • 12. Luciano Gattinoni, John J. Marini, Antonio Pesenti, Michael Quintel, Jordi Mancebo, Laurent Brochard. The "baby lung" became an adult. Intensive Care Med. 2016; 42(5): pp. 663–673. doi: 10.1007/s00134-015-4200-8.
  • 13. E. A. Amsterdam, N. K. Wenger, R. G. Brindis, D. E. Casey Jr., T. G. Ganiats, D. R. Holmes Jr., A. S. Jaffe, H. Jneid, R. F. Kelly, M. C. Kontos, G. N. Levine, P. R. Liebson, D. Mukherjee, E. D. Peterson, M. S. Sabatine, R. W. Smalling, S. J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. http://www.onlinejacc.org/content/64/24/e139. Updated December 24, 2014. Accessed April 16, 2019.
  • 14. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2012; 127(4): pp. 529–555. doi: 10.1161/cir.0b013e3182742c84.
  • 15. Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349(7): pp. 684–690. doi: 10.1056/nejmra022643.
  • 16. Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med. 2018; 55(5): pp. 635–646. doi: 10.1016/j.jemermed.2018.08.002.
  • 17. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017; 136(6). doi: 10.1161/cir.0000000000000509.
  • 18. Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol. 2013; 62(16): pp. 1495–1539. doi: 10.1016/j.jacc.2013.05.020.
  • 19. Van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017; 136(16). doi: 10.1161/cir.0000000000000525.
  • 20. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014; 64(21): pp. e1–e76. doi: 10.1016/j.jacc.2014.03.022.
  • 21. CECILIA GUTIERREZ, MD, and DANIEL G. BLANCHARD, MD. Diagnosis and Treatment of Atrial Fibrillation. Am fam physician. 2016.
  • 22. Karen K. Stout, Edward D. Verrier. Acute Valvular Regurgitation. Circulation. 2009; 119(25): pp. 3232–3241. doi: 10.1161/circulationaha.108.782292.
  • 23. Long B, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. Western Journal of Emergency Medicine. 2019; 20(4): pp. 587–600. doi: 10.5811/westjem.2019.5.42650.
  • 24. Moellman JJ, Bernstein JA, Lindsell C, et al. A Consensus Parameter for the Evaluation and Management of Angioedema in the Emergency Department. Academic Emergency Medicine. 2014; 21(4): pp. 469–484. doi: 10.1111/acem.12341.
  • 25. Hewlett JC, Rickman OB et al. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis. 2017; 9(9): pp. 3398–3409. doi: 10.21037/jtd.2017.06.137.
  • 26. Alcaide ML, Bisno AL. Pharyngitis and Epiglottitis. Infect Dis Clin North Am. 2007; 21(2): pp. 449–469. doi: 10.1016/j.idc.2007.03.001.
  • 27. Lindquist B et al. Adult Epiglottitis: A Case Series. The Permanente Journal. 2016. doi: 10.7812/tpp/16-089.
  • 28. Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency Imaging Assessment of Deep Neck Space Infections. Seminars in Ultrasound, CT and MRI. 2012; 33(5): pp. 432–442. doi: 10.1053/j.sult.2012.06.008.
  • 29. Dargan PI. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emergency Medicine Journal. 2002; 19(3): pp. 206–209. doi: 10.1136/emj.19.3.206.
  • 30. American College of Medical Toxicology. Guidance document: management priorities in salicylate toxicity. Journal of medical toxicology : official journal of the American College of Medical Toxicology. 2015; 11(1): pp. 149–52. doi: 10.1007/s13181-013-0362-3.
  • 31. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009; 32(7): pp. 1335–1343. doi: 10.2337/dc09-9032.
  • 32. Westerberg D. Diabetic Ketoacidosis: Evaluation and Treatment. Am Fam Physician. 2013. url: https://www.aafp.org/afp/2013/0301/p337.html#afp20130301p337-b19.
  • 33. Hampson NB, Piantadosi CA, Thom SR, Weaver LK. Practice Recommendations in the Diagnosis, Management, and Prevention of Carbon Monoxide Poisoning. Am J Respir Crit Care Med. 2012; 186(11): pp. 1095–1101. doi: 10.1164/rccm.201207-1284ci.
  • 34. Hampson NB. Myth busting in carbon monoxide poisoning. Am J Emerg Med. 2016; 34(2): pp. 295–297. doi: 10.1016/j.ajem.2015.10.051.
  • 35. Alder L, Tambe A. Acute Anemia. https://www.ncbi.nlm.nih.gov/pubmed/30725917. Updated April 24, 2019. Accessed November 6, 2019.
  • 36. Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB. JAMA. 2016; 316(19): p. 2025. doi: 10.1001/jama.2016.9185.
  • 37. Morgan WC, Hodge HL. Diagnostic evaluation of dyspnea. Am Fam Physician. 1998; 57(4): pp. 711–716. pmid: 9490994.
  • 38. Zoorob RJ, Campbell JS. Acute dyspnea in the office. Am Fam Physician. 2003; 68(9): pp. 1803–1811. pmid: 14620600.
  • 39. Lechtzin N. Dyspnea. https://www.merckmanuals.com/professional/pulmonary-disorders/symptoms-of-pulmonary-disorders/dyspnea. Updated April 1, 2018. Accessed November 4, 2019.
  • 40. Berliner D, Schneider N, Welte T, Bauersachs J. The differential diagnosis of dyspnea. Dtsch Arztebl Int. 2016; 113(49): pp. 834–845. doi: 10.3238/arztebl.2016.0834.
  • Ko DR, Chung YE, Park I, et al. Use of Bedside Sonography for Diagnosing Acute Epiglottitis in the Emergency Department. Journal of Ultrasound in Medicine. 2012; 31(1): pp. 19–22. doi: 10.7863/jum.2012.31.1.19.
  • Gregor P, Čurila K. Medical treatment of hypertrophic cardiomyopathy - What do we know about it today?. Cor Vasa. 2015; 57(3): pp. e219–e224. doi: 10.1016/j.crvasa.2015.02.003.
  • Díez-López C, Salazar-Mendiguchía J. Clinical presentations of hypertrophic cardiomyopathy and implications for therapy. Global Cardiology Science and Practice. 2018; 2018(3). doi: 10.21542/gcsp.2018.19.
  • Casu G, Merella P. Diuretic Therapy in Heart Failure – Current Approaches. European Cardiology Review. 2015; 10(1): p. 42. doi: 10.15420/ecr.2015.10.01.42.
  • Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary. J Am Coll Cardiol. 2011; 58(25): pp. 2703–2738. doi: 10.1016/j.jacc.2011.10.825.
  • V. Sherrid M. Drug Therapy for Hypertrophic Cardiomypathy: Physiology and Practice. Current Cardiology Reviews. 2016; 12(1): pp. 52–65. doi: 10.2174/1573403x1201160126125403.
  • Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2013; 118(2): pp. 251–270. doi: 10.1097/aln.0b013e31827773b2.
  • Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017; 50(2): p. 1602426. doi: 10.1183/13993003.02426-2016.
  • Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017; 119(3): pp. 369–383. doi: 10.1093/bja/aex228.
  • Frossard JL, Spahr L, Queneau PE, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: A randomized, controlled, double-blind trial. Gastroenterology. 2002; 123(1): pp. 17–23. doi: 10.1053/gast.2002.34230.
  • Campbell RL, Li JTC, Nicklas RA, Sadosty AT. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113(6): pp. 599–608. doi: 10.1016/j.anai.2014.10.007.
  • Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Philadelphia, PA: Elsevier Health Sciences; 2018.
  • Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018; 49(3). doi: 10.1161/str.0000000000000158.
  • Loprinzi Brauer, et al. Prospective Validation of the NIAID/FAAN Criteria for Emergency Department Diagnosis of Anaphylaxis. JACI: In Practice. 2016; 4(6). doi: 10.1016/j.jaip.2016.06.003.
  • Stoller JK. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2002; 346(13): pp. 988–994. doi: 10.1056/nejmcp012477.
  • Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2020 Report. http://www.goldcopd.org. Accessed June 27, 2019.
  • Hampson NB, Courtney TG, Holm JR. Diffusion of Carbon Monoxide Through Gypsum Wallboard. JAMA. 2013; 310(7): p. 745. doi: 10.1001/jama.2013.43127.
  • Caro DA. Basic Airway Management. Philadelphia: Saunders/Elsevier; 2013: pp. 1–7.
  • January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2019; 74(1): pp. 104–132. doi: 10.1016/j.jacc.2019.01.011.
  • American Thoracic Society. International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Am J Respir Crit Care Med. 2001; 163(1): pp. 283–291. doi: 10.1164/ajrccm.163.1.ats1000.
  • Thim T, Krarup NHV, Grove EL, Rohde CV, Lofgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012; 5: pp. 117–121. doi: 10.2147/ijgm.s28478.
  • Juurlink DN, Gosselin S, Kielstein JT, et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. 2015; 66(2): pp. 165–181. doi: 10.1016/j.annemergmed.2015.03.031.
  • Stolbach AI, Hoffman RS, Nelson LS. Mechanical Ventilation Was Associated with Acidemia in a Case Series of Salicylate-poisoned Patients. Academic Emergency Medicine. 2008; 15(9): pp. 866–869. doi: 10.1111/j.1553-2712.2008.00205.x.
  • Lawson-Smith P, Jansen EC, Hyldegaard O. Cyanide intoxication as part of smoke inhalation - a review on diagnosis and treatment from the emergency perspective. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19(1): p. 14. doi: 10.1186/1757-7241-19-14.
  • Kollmeier BR, Keenaghan M. Aspiration Risk. https://www.ncbi.nlm.nih.gov/pubmed/29262188. Updated January 1, 2019. Accessed November 15, 2019.
  • Ashton RW, Burkle CM. Endotracheal Intubation by Direct Laryngoscopy. https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/critical-care-procedures/endotracheal-intubation-by-direct-laryngoscopy.php. Updated May 1, 2004. Accessed November 15, 2019.
  • Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis—a practice parameter update 2015. Annals of Allergy, Asthma & Immunology. 2015; 115(5): pp. 341–384. doi: 10.1016/j.anai.2015.07.019.
  • Rudkin S, Cerejo R, Tayal A, Goldberg MF. Imaging of acute ischemic stroke. Emerg Radiol. 2018; 25(6): pp. 659–672. doi: 10.1007/s10140-018-1623-x.
last updated 02/03/2020
{{uncollapseSections(['k11mSf0', 'M11Mhf0', '3U1S1T0', 'l11vSf0', 'N11-Sf0', 'm11Vhf0', '511ihf0', 'O11ISf0'])}}