Evaluation of the adult with dyspnea in the emergency department
- Azeemuddin Ahmed, MD, MBA
Azeemuddin Ahmed, MD, MBA
- Clinical Professor of Emergency Medicine
- University of Iowa Carver College of Medicine
- Mark A Graber, MD, MSHCE, FACEP
Mark A Graber, MD, MSHCE, FACEP
- Clinical Professor of Emergency Medicine and Family Medicine
- University of Iowa Carver College of Medicine
Dyspnea is the perception of an inability to breathe comfortably . The adult patient with acute dyspnea presents difficult challenges in diagnosis and management. The emergency clinician must work through a wide differential diagnosis while providing appropriate initial treatment for a potentially life-threatening illness. Airway, breathing, and circulation are the emergency clinician's primary focus when beginning management of the acutely dyspneic patient. Once these are stabilized, further clinical investigation and treatment can proceed.
For the purpose of this review, we will use the term "dyspnea" to encompass all patients with disordered or inadequate breathing. This topic review will provide a differential diagnosis of the life-threatening and common causes of dyspnea in the adult, describe important historical and clinical findings that can help to narrow the differential diagnosis, discuss the use of common diagnostic studies, and provide recommendations for initial management and disposition. Detailed discussions of specific diagnoses are found elsewhere in the program.
The respiratory system is designed to maintain homeostasis with respect to gas exchange and acid-base status. Derangements in oxygenation as well as acidemia lead to breathing discomfort. The development of dyspnea is a complex phenomenon generally involving stimulation of a variety of mechanoreceptors throughout the upper airway, lungs, and chest wall, and chemoreceptors at the carotid sinus and the medulla. The pathophysiology of dyspnea is discussed in detail elsewhere. (See "Physiology of dyspnea" and "Oxygenation and mechanisms of hypoxemia".)
Dyspnea is a common chief complaint among patients who come to the emergency department (ED). A chief complaint of dyspnea or shortness of breath made up 3.7 million visits (2.7 percent) of the more than 136 million visits to United States EDs in 2011. Other dyspnea-related chief complaints (cough, chest discomfort) comprised 8.2 percent . In males and females over the age of 65 years old, dyspnea and related problems were a major reason for ED visits .
According to one prospective observational study, the most common diagnoses among elderly patients presenting to an ED with a complaint of acute shortness of breath and manifesting signs of respiratory distress (eg, respiratory rate >25, SpO2 <93 percent) are decompensated heart failure, pneumonia, chronic obstructive pulmonary disease, pulmonary embolism, and asthma .
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- DIFFERENTIAL DIAGNOSIS
- Life-threatening upper airway causes
- Life-threatening pulmonary causes
- Life-threatening cardiac causes
- Life-threatening neurologic causes
- Life-threatening toxic and metabolic causes
- Miscellaneous causes
- PHYSICAL EXAMINATION
- Clinical danger signs
- General examination findings
- ANCILLARY STUDIES
- General approach
- Plain chest radiograph (CXR)
- Cardiac biomarkers
- Brain natriuretic peptide
- Arterial and venous blood gas
- Carbon dioxide monitoring
- Chest CT and VQ scan
- Peak flow and pulmonary function tests (PFTs)
- Negative inspiratory force
- Initial interventions and differential diagnosis
- Emergent management
- Nonemergent management
- PITFALLS IN MANAGEMENT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS