Acute Dyspnea in the Office ROGER J. ZOOROB, M.D., M.P.H., and JAMES S. CAMPBELL, M.D. Louisiana State University School of Medicine, Kenner, Louisiana Respiratory difficulty is a common presenting complaint in the outpatient primary care set- ting. Because patients may first seek care by calling their physician’s office, telephone triage plays a role in the early management of dyspnea. Once the patient is in the office, the initial goal of assessment is to determine the severity of the dyspnea with respect to the need for oxygenation and intubation. Unstable patients typically present with abnormal vital signs, altered mental status, hypoxia, or unstable arrhythmia, and require supplemental oxygen, intravenous access and, possibly, intubation. Subsequent management depends on the dif- ferential diagnosis established by a proper history, physical examination, and ancillary stud- ies. Dyspnea is most commonly caused by respiratory and cardiac disorders. Other causes may be upper airway obstruction, metabolic acidosis, a psychogenic disorder, or a neuro- muscular condition. Differential diagnoses in children include bronchiolitis, croup, epiglotti- tis, and foreign body aspiration. Pertinent history findings include cough, sore throat, chest pain, edema, and orthopnea. The physical examination should focus on vital signs and the heart, lungs, neck, and lower extremities. Significant physical signs are fever, rales, wheez- ing, cyanosis, stridor, or absent breath sounds. Diagnostic work-up includes pulse oximetry, complete blood count, electrocardiography, and chest radiography. If the patient is admitted to the emergency department or hospital, blood gases, ventilation-perfusion scan, D-dimer tests, and spiral computed tomography can help clarify the diagnosis. In a stable patient, management depends on the underlying etiology of the dyspnea. (Am Fam Physician 2003; 68:1803-10. Copyright© 2003 American Academy of Family Physicians.) hortness of breath, or dyspnea, is a tem, motor cortex, and peripheral receptors in common problem in the outpatient the upper airway, lungs, and chest wall.1 Vari- primary care setting. Establishing a ous disease states can produce dyspnea in diagnosis can be challenging slightly different manners, depending on the because dyspnea appears in multiple interaction of efferent signals with receptors Sdiagnostic categories. Underlying disorders of the central nervous system, autonomic sys- range from the relatively simple to the more tem, and peripheral nerves. The actual sensa- serious, which are best addressed in an emer- tion of muscular effort and breathlessness gency department. Timely assessment, diag- results from the simultaneous activation of nosis, and initiation of appropriate therapy the sensory cortex at the time the chest mus- play an important role in controlling the cles are signaled to contract.2 Good evidence commonly associated anxiety. Family physi- demonstrates that increased carbon dioxide cians should be prepared and equipped to partial pressure (PCO2) levels stimulate the triage, manage, and stabilize patients with feeling of breathlessness independent of the acute dyspnea. effects of ventilation or the oxygen partial 2 pressure (PO2) level. Pathophysiology Dyspnea is described as faster breathing Clinical Presentation and Triage accompanied by the sensations of running out At presentation, an adult patient usually of air and of not being able to breathe fast or describes a sensation of difficult or uncom- deeply enough. The sensations are similar to fortable breathing. Triage begins with deter- that of thirst or hunger (i.e., an unignorable mining the degree of urgency by assessing the feeling of needing something). Dyspnea duration of the condition, whether it is acute results from multiple interactions of signals or chronic, and the severity of symptoms. and receptors in the autonomic nervous sys- Studies have shown that the type and severity Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2003 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Telephone Triage for Acute Dyspnea Children Adults <3 months of age Severe dyspnea or or sudden onset new dyspnea at rest or or sore throat sudden onset of chest pain or croupy cough or No No Yes lethargy or History of CHF History of COPD ED temperature above 38.8°C (102°F) or or progressive dyspnea history of asthma and progress dyspnea Yes No Inform physician • Increase diuretic Inform physician ED Same-day • Weigh daily • Adjust bronchodilator dosage office visit • Advise office visit or • Add corticosteroid ED visit as indicated • Consider antibiotics • Home health visit • Advise office visit or ED visit as indicated • Home health visit FIGURE 1. Telephone triage of acute dyspnea in the physician’s office. (CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; ED = emergency department) of an underlying lung or heart disease corre- Unstable patients typically present with one lates well with the way the patient describes or more symptom patterns: the dyspnea.3 The first communication with • Hypotension, altered mental status, the physician’s office, especially for established hypoxia, or unstable arrhythmia. patients, may be by telephone. Telephone • Stridor and breathing effort without air triage is an important initial step in manage- movement (suspect upper airway obstruction). ment. Protocols and clearly written office pro- • Unilateral tracheal deviation, hypoten- cedures for staff are recommended to provide sion, and unilateral breath sounds (suspect proper care and minimize risk.4 A triage algo- tension pneumothorax) rithm (Figure 1) can be used by office nurses. • Respiratory rate above 40 breaths per minute, retractions, cyanosis, low oxygen Recognition and Management saturation. of Unstable Patients The same initial treatment process should Definitive care, which must follow stabi- be applied for any of these symptom patterns. lization, depends on the specific diagnosis. First, administer oxygen. Consider intubation An initial quick assessment will help the if the patient is working to breathe (gasping), physician determine if a patient is unstable apneic, or nonresponsive, following advanced (Table 1). cardiac life support (ACLS) guidelines.5 Next, establish intravenous line access and start administration of fluids. Perform needle Studies have shown that the type and severity of an under- thoracentesis in patients with tension pneu- mothorax. Administer a nebulized bron- lying lung or heart disease correlates well with the way the chodilator if obstructive pulmonary disease is patient describes the dyspnea. present.Administer intravenous or intramuscu- lar furosemide if pulmonary edema is present. 1804 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 68, NUMBER 9 / NOVEMBER 1, 2003 Dyspnea TABLE 1 Once an emergent situation has been excluded, the patient’s Initial Assessment of Patients airway, mental status, ability to speak, and breathing effort with Dyspnea should be reevaluated. A focused history should be obtained, Assess airway patency and listen to the lungs. and a physical examination completed. Observe breathing pattern, including use of acces- sory muscles. Monitor cardiac rhythm. In children, the most common causes of Measure vital signs and pulse oximetry. Obtain any history of cardiac or pulmonary disease, acute dyspnea are acute asthma, pulmonary or trauma. infections, and upper airway obstruction. Evaluate mental status. Some conditions associated with dyspnea, such as epiglottitis, croup, myocarditis, asthma, and diabetic ketoacidosis, are serious and may be fatal. In children, always consider Disposition and transfer of the patient foreign body aspiration, croup, and bronchi- depends on the diagnosis or differential diag- olitis caused by respiratory syncytial virus.8,9 nosis. Unstable patients should be transported to the closest emergency department for fur- HISTORY ther evaluation and treatment. Trained health A complete history should emphasize any care personnel should accompany the patient coexisting cardiac and pulmonary symptoms. in the ambulance and continue management Cardiac and pulmonary problems are the until supervision is transferred to the emer- most common causes of dyspnea. Determine gency department team. onset, duration, and occurrence at rest or exertion. The presence of cough may imply Further Assessment of Stable Patients asthma or pneumonia; cough combined with Once an emergent situation has been a change in the character of sputum may be excluded, obtain a history to determine the caused by exacerbation of chronic obstructive level of acuity. Reassess the patient’s airways, pulmonary disease (COPD). In adults, mental status, ability to speak, and breathing effort. Check vital signs, and question the patient (or a family member) about the dura- TABLE 2 tion of the dyspnea and any underlying car- Differential Diagnosis of Acute Dyspnea in Adults diac or pulmonary disease. Include a focused history of medication use, cough, fever, and Cardiac: congestive heart failure, coronary artery disease, arrhythmia, chest pain. Ask about any history of trauma pericarditis, acute myocardial infarction, anemia and continue the focused physical examina- Pulmonary: chronic obstructive pulmonary disease, asthma, pneumonia, tion by listening to breath sounds and observ- pneumothorax, pulmonary embolism, pleural effusion, metastatic disease,