DESCRIPTION

Respiratory distress, shortness of breath, or dyspnea is a common complaint for patients presenting to the ED.

ETIOLOGY

• Upper airway obstruction:
  • Epiglottitis
  • Croup syndromes
  • Laryngotracheobronchitis
  • Foreign body
  • Angioedema
  • Retropharyngeal abscess
• Cardiovascular:
  • Pulmonary edema/CHF
  • Dysrhythmias
  • Cardiac ischemia
  • Pulmonary embolus
  • Pericarditis
  • Tamponade
  • Air embolism
• Pulmonary:
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)/emphysema
  • Pneumonia
  • Influenza
  • Bronchiolitis
  • Aspiration
  • Adult respiratory distress syndrome (ARDS)
  • Pulmonary edema
  • Pleural effusion
  • Toxic inhalation injury
• Trauma:
  • Pneumothorax
  • Tension pneumothorax
  • Rib fractures
  • Pulmonary contusion
  • Fat embolism with long-bone fractures
• Neuromuscular:
  • Guillain–Barré syndrome
  • Myasthenia gravis
• Metabolic/systemic/toxic:
  • Anaphylaxis
  • Anemia
  • Acidosis
  • Hyperthyroidism
  • Sepsis
  • Septic emboli from IV drug use or infected indwelling lines
  • Salicylate intoxication
  • Drug overdose
  • Amphetamines
  • Cocaine
  • Sympathomimetic
  • Obesity
• Psychogenic:
  • Anxiety disorder
  • Hyperventilation syndrome
• Bioterrorist threats:
  • Anthrax
  • Pneumonic plague
  • Tularemia
  • Viral hemorrhagic fevers

Pediatric Considerations

• Respiratory failure is the most common cause of cardiac arrest in infants.
• Croup syndromes include:
  • Viral
  • Spasmodic
  • Bacterial
  • Congenital defects
  • Noninflammatory causes (foreign body, gastroesophageal reflux, trauma, tumors)
• Most common cause of upper airway obstruction:
  • < 6 mo: Congenital laryngomalacia
  • > 6 mo: Viral croup
• Epiglottitis:
  • Highest incidence at ages 2–4 yr
  • Abrupt onset
  • Fever
  • Respiratory distress and stridor
  • Difficulty swallowing oral secretions
  • Restlessness and anxiety

Pediatric Considerations

• Amniotic fluid embolism during or after delivery
• Septic embolism from septic abortion or postpartum uterine infection

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Tachypnea
• Dyspnea
• Tachycardia
• Anxiety
• Diaphoresis
• Cough ("barking," productive)
• Stridor
• Hoarse voice
• Difficulty swallowing or handling oral secretions
• Upper airway rhonchi (wheezes)
• Lower airway crackles (rales)
• Increased work of breathing
• Accessory and intercostal muscle use
• Hypoxemia
• Hypocapnia or hypercapnia if severe
• Respiratory acidosis
• Cyanosis
• Lethargy, then obtundation

History

• Previous history of asthma, COPD, cardiac disease, or dysrhythmia, CHF, foreign-body aspiration, or toxic exposure
• Recent fever or upper respiratory tract infection, cough, sputum production, sore throat, systemic disease, anxiety disorder
• Recent chest or long-bone trauma
• IV drug use or indwelling catheters
• Recurrent fevers, night sweats, weight loss

Physical Exam

• Observe: Mental status, level of distress, work of breathing, jugular venous pressure, skin color
• Feel/palpate: Distal pulses, heart perioperative MI, chest wall, peripheral edema
• Percuss: Lungs for dullness or resonance, abdominal distention, or hepatomegaly
• Auscultate: Heart sounds, murmurs, lung wheezes or crackles, neck for upper airway stridor, abdomen bowel sounds

Pediatric Considerations

• Evaluate retractions, behavior, respiratory rate, breath sounds, and skin color.
• Weak cry, expiratory grunting, nasal flaring, tachypnea and tachycardia, retractions, and cyanosis in neonates

ESSENTIAL WORKUP

• Pulse oximetry
• Cardiac and BP monitoring
• EKG if suspected cardiac etiology

DIAGNOSIS TESTS & INTERPRETATION

Lab

• ABG for severity and acid–base determination
• CBC
• Electrolytes, BUN/creatinine, glucose
• Sputum cultures, smears, and Gram stain
• Blood cultures for fever or sepsis
• B-type natriuretic peptide (BNP) for undifferentiated shortness of breath or CHF severity
• Venous thromboembolus test (VTE) for low-risk PE
• HIV
• Seasonal and "novel" flu testing
• Urinary output monitoring for CHF
• Toxicology screen or salicylate level if suspected

Imaging

• CXR for:
  • Pneumonia
  • Pneumothorax
  • Hyperinflation
  • Atelectasis
  • CHF/pulmonary edema
  • Abscess/cavitary lesions/other infiltrates
  • Tuberculosis
• Ultrasound for:
  • Lung and rib evaluation using linear transducer
  • Pneumothorax
  • Hemothorax/pleural effusion
  • CHF
  • Rib fractures
• Echocardiography using phased array transducer:
  • Cardiac effusion/tamponade
  • CHF/cardiac dilatation
  • RV dilatation for PE
• Spirometry (peak expiratory flow rates) for asthma, COPD
• Neck CT or radiographs to assess epiglottis and soft-tissue spaces, foreign body
• CT angiography or ventilation/perfusion scan for pulmonary embolus

Pediatric Considerations

• Chest/neck radiograph may show foreign body or "steeple sign" in croup syndromes.
• Chest fluoroscopy may be used to assess inspiratory and expiratory excursions if foreign body is suspected.

Diagnostic Procedures/Surgery

• Fiberoptic laryngoscopy to assess epiglottis, vocal cords, and pharyngeal space
• Bronchoscopy for foreign body in trachea or bronchus
• Pulmonary artery (Swan-Ganz) catheter for severe CHF, ARDS, pulmonary edema

DIFFERENTIAL DIAGNOSIS

See Etiology.

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

PRE-HOSPITAL

• Assume a position of comfort for patient.
• 100% oxygen:
  • Assisted bag-valve mask (BMV) ventilation if obtunded
• Airway adjunct devices (oral or nasal) to maintain patency if tolerated
• Intubation for severe respiratory distress
• Needle aspiration of suspected tension pneumothorax

INITIAL STABILIZATION/THERAPY

• ABCs
• Ensure patent airway; BVM assist or intubate for severe distress or arrest
• IV fluids if hypotensive
• 100% oxygen by face mask:
  • Use cautiously in patients with severe COPD or chronic CO₂ retention.
• Monitor BP, heart rate, respirations, pulse oximetry
• Advanced cardiac life support for dysrhythmias or arrest

ED TREATMENT/PROCEDURES

• Treat underlying etiology as appropriate.
• CHF or pulmonary edema:
  • Diuretics
  • Nitroglycerin
  • Nitroprusside if hypertensive
  • Pulmonary artery catheter if severe
  • Noninvasive positive-pressure ventilation (NPPV/BiPAP) or intubation if severe
• Asthma, bronchiolitis, COPD:
  • Bronchodilators
  • Steroids
  • Antibiotics for infection
  • Antivirals for influenza
  • NPPV or intubation if severe
• ARDS, aspiration, toxic lung injury:
  • Mechanical ventilation as needed
  • Steroids controversial
• Pneumonia:
  • Antibiotics
  • Respiratory isolation for TB
• Pneumothorax:
  • Immediate decompression if suspected tension pneumothorax
  • Aspiration or tube thoracostomy (see Pneumothorax)
• Pleural effusion:
  • Determine etiology
  • Diagnostic and symptomatic thoracentesis
• Croup:
  • Cool, misted air or oxygen
  • Steroids
  • Racemic epinephrine
  • Antibiotics for bacterial infection
• Epiglottitis:
  • Immediate airway stabilization with intubation or tracheostomy in OR if possible
  • Antibiotics for Haemophilus influenzae
• Anaphylaxis, angioedema:
  • IV steroids
  • H₁/H₂-blockers
  • SQ or IV epinephrine
  • Early intubation
• Retropharyngeal abscess:
  • Drainage
  • IV antibiotics
  • ENT consult
• Cardiac:
  • Treat dysrhythmias or ischemia
  • Anticoagulation or thrombolysis for PE
  • Pericardiocentesis for tamponade
  • NSAIDs or aspirin for pericarditis
• Neuromuscular:
  • Support ventilation
  • Pyridostigmine bromide or neostigmine for myasthenia gravis
• Metabolic/toxic:
  • Treat underlying cause
• Psychogenic:
  • Anxiolytics

Pediatric Considerations

• Transtracheal jet ventilation if unable to intubate (cricothyrotomy not recommended in children < 10 yr)
• Bronchiolitis:
  • Bronchodilators
  • Antivirals for respiratory syncytial virus
  • Antibiotics for infection
• Spasmodic croup:
  • Very sensitive to misted air
• Bacterial croup (membranous laryngotracheobronchitis):
  • Treat Staphylococcus aureus.

Pregnancy Considerations

• Supportive oxygen therapy and heparin for PE or amniotic fluid embolism
• IV antibiotics for septic embolism

MEDICATION

Refer to specific etiologies

[Outline]

• PRE-HOSPITAL
• INITIAL STABILIZATION/THERAPY
• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Continued supplemental oxygen requirement
• Cardiac or hemodynamic instability:
  • Requiring IV therapy or hydration
  • Requiring close airway observation or repeated treatments
  • Respiratory isolation
• As required by underlying cause or significant comorbid disease

Discharge Criteria

• Correction of underlying disease
• Stable airway
• Acute supplemental oxygen not required

Issues for Referral

Refer to specific etiologies

• Consider immune-compromised state.
• Consider "novel" flu strains (H1N1).
• Start antibiotic treatment within 6 hr of ED arrival (JCAHO Quality Measure).

ICD9

• 786.00 Respiratory abnormality, unspecified
• 786.05 Shortness of breath
• 786.09 Other respiratory abnormalities

ICD10

• R06.00 Dyspnea, unspecified
• R06.02 Shortness of breath
• R06.09 Other forms of dyspnea

[Outline]

• ICD9
• ICD10

• Ausiello D, Goldman L, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia, PA: WB Saunders; 2004:492–583, 1523–1524.
• Barton ED, Collings J, DeBlieux PMC, et al., eds. Emergency Medicine: Clinical Essentials. 2nd ed. Philadelphia, PA: Elsevier Saunders; 2009:43–49, 173, 398, 414–434, 476–486, 1351–1368.
• Sigillito RJ, DeBlieux PM. Evaluation and initial management of the patient in respiratory distress. Emerg Med Clin North Am. 2003;21(2):239–258.
• Williams SA, Hutson HR, Speals HL. Dyspnea. In: Emergency Medicine: Concepts and Clinical Practice. 4th ed. St. Louis, MO: Mosby; 1998:1460–1469.

Erik D. Barton

Joy English