Acute dyspnea

This page is for adult patients. For pediatric patients, see: acute dyspnea (peds).

Clinical Features

Emergent Pattern Recognition

Diagnosis	Lungs	CXR	ECG	Treatment	Contraindicated
Pulmonary Edema	Bilateral rales	Interstitial fluid	Normal/abnormal	R/O AMI, lasix, nitrates, ACEi, BiPAP	IVF; ?albuterol; ?Beta-blockers
Bronchoconstriction	Wheezes	Clear/hyperinflated	Normal/pulmonary strain	Albuterol, atrovent, steroids, consider anaphylaxis (epi)	Beta-blockers; ?aspirin
Pneumonia	Focal ronchi/decreased breath sounds	Infiltrate/effusion	Normal	IVF, antibiotics	Rate control; diuresis
Pulmonary embolism	Clear	Clear (most) or Westrmark/Hampton hump	Normal/S1Q3T3	Anticoagulate/thrombolytics	Rate control
Pneumothorax/Hemothorax	Unequal	Pneumo/hemo	Normal	Needle thoracentesis/chest tube	Rate control
Dysrythmia	Clear/pulmonary edema	Clear/pulmonary edema	Abnormal	Type dependent	Albuterol; ?IVF
ACS	Clear/pulmonary edema	Clear/pulmonary edema	Normal/abnormal	Aspirin; nitrates, anticoagulation, ?beta-blockers, +/- thrombolytics	Albuterol; ?IVF

Differential Diagnosis

Acute dyspnea

Emergent

• Pulmonary
  • Airway obstruction
  • Anaphylaxis
  • Angioedema
  • Aspiration
  • Asthma
  • Cor pulmonale
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
  • Cystic fibrosis exacerbation
• Cardiac
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
  • Myocarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Salicylate toxicity
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Epiglottitis
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumonia
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Lambert-Eaton Syndrome
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Fever
• Hyperventilation
• Interstitial lung disease
• Neoplasm
• Obesity
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease
• URI

Evaluation

Pulmonary edema with small pleural effusions on both sides.

• CXR
• ECG
• CBC
• Chem-7
• BNP?
• D-dimer?
• Troponin?
• ABG?
• Bedside ultrasound?

Bedside Lung Ultrasound in Emergency (BLUE) Protocol

Algorithm for the Use of Ultrasound in the Evaluation of Dyspnea

• Predominant A lines + lung sliding = Asthma/COPD
• Multiple predominant B lines anteriorly with lung sliding = Pulmonary Edema
• Normal anterior profile + DVT= PE
• Anterior absent lung sliding + A lines + lung point = Pneumothorax (PTX)
• Anterior alveolar consolidations, anterior diffuse B lines with abolished lung sliding, anterior asymmetric interstitial patterns, posterior consolidations or effusions with out anterior diffuse B lines = Pneumonia

Management

• Oxygen
• Treat underlying cause

See Also

• Hypoxemia
• Shortness of breath (peds)

Video

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