Breathless patients are a challenge in the ED. Shortness of
breath can be a frightening presenting complaint for both patients and
doctors. As always, think about the possible life threatening causes and
actively rule them out. For breathless patients think especially about:
this podcast Iain and Simon discuss their approach to
breathless patients in the ED which we hope will provide you with a good
- Oxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills
- Always rule out life threatening causes first
- These patients are sick - do not be afraid to ask advice from a senior colleague early
- Look for clues - you don't have to wait until the penultimate page of the story to solve the mystery.
What have you learned about breathless patients?
Oxygen - or no oxygen??
Oxygen administration is rarely a problem in the immediate and acute
setting - and can save lives. So yes, when you first approach a patient
who is short of breath, get that oxygen on while you make your
assessment then think about the finer points of respiratory failure
Where do I begin?
A focused history, including asking the patient about previous conditions and whether they know what's going on!
And then - initial assessment and examination including vital signs
(especially respiratory rate), looking for clues as to the underlying
cause of their breathlessness, remembering the five common causes.
What treatments might be useful?
A small fluid bolus might help and carries relatively little risk;
think about the need for nebulised bronchodilators for patients with
asthma or COPD, and remember that antibiotics given early to patients
with sepsis save lives.
If the patient has pain we should definitely treat that too.
Which investigations might help me find out more?
chest x-ray is often useful in patients who are short of breath; your
ED seniors might be able to use bedside ultrasound to further ascertain
the underlying pathology, so get help early!
- ECGs are often useful in these patients
gases can also provide lots of useful information - think carefully
about whether you need arterial gases and if so, please use local
- If nothing makes sense - get a blood sugar,
remembering that metabolic disease may cause an acidosis, presenting
with an increased respiratory rate (although not often true dyspnoea).
GET SENIOR HELP (including getting your seniors to assess you for those
all-important workplace-based assessments; definitely start those
of the key investigations in patients with shortness of breath is the
humble chest radiograph. There are some phenomenal FOAM resources for
interpretation of CXRs (along with other XRs) at Radiology Masterclass. Well worth bookmarking for your ED shifts (but do ask a senior if you're unsure).
Chest X-Ray Anatomy - Chest X-Ray Abnormalities - Chest X-Ray Systematic Approach
Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you...
Further Reading on Shortness of Breath
The Flipped EM Classroom - Shortness of Breath (with further links).