Dyspnea in the Emergency Department: Structured Evaluation and Management

Dyspnea (subjective breathing discomfort) is a high-acuity ED complaint. Rapid differentiation of life-threatening vs. stable causes is critical.

Immediate Triage (ABCs)

• Airway patent? Breathing effort? Circulation?
• O₂ saturation, cardiac monitor, IV access.
• Consider immediate intubation for: apnea, GCS <8, severe hypoxia unresponsive to O₂, fatigue, hemodynamic instability.

Focused History (OPQRST + Specifics)

• Onset: Sudden (PE, pneumothorax, MI, aspiration) vs. gradual (COPD, HF, pneumonia).
• Provocation: Exertion (cardiac, COPD), position (orthopnea = HF, platypnea = shunt), meals (aspiration).
• Quality: "Air hunger" (metabolic acidosis), "tightness" (asthma), "crushing" (MI).
• Associated: Chest pain, cough, hemoptysis, fever, syncope, leg swelling.
• Past History: Cardiac, pulmonary, DVT/PE, cancer, medications.

Physical Exam Priorities

• Vitals: RR, SpO₂, BP, HR, temp. Pulsus paradoxus (asthma, tamponade, COPD).
• Respiratory: Accessory muscle use, tripoding, tracheal deviation, asymmetric expansion, percussion (hyperresonance = pneumothorax, dullness = effusion), auscultation (wheeze, crackles, absent breath sounds, stridor).
• Cardiac: JVD, S3/S4, murmur, rub.
• Extremities: Edema, calf tenderness (DVT).

Diagnostic Testing

• Bedside: ECG (STEMI, strain, right heart), POCUS (B-lines = pulmonary edema, pleural effusion, IVC collapsibility, RV dilation = PE, sliding lung = pneumothorax), capnography.
• Labs: CBC, BMP, troponin, BNP/NT-proBNP, D-dimer (if PE low/mod prob), VBG/ABG (pH, PaCO₂, lactate), coags.
• Imaging: CXR (first-line), CTPA (PE), CT aorta (dissection), echo (bedside/formal).

Differential by System

System	Life-Threatening	Urgent/Common
Cardiac	MI, acute HF, tamponade, massive PE	Arrhythmia, valvular, cardiomyopathy
Pulmonary	Tension pneumothorax, massive PE, severe asthma/COPD, airway obstruction	Pneumonia, pleural effusion, mild-mod asthma/COPD
Other	Anaphylaxis, metabolic acidosis (DKA, sepsis), thyrotoxicosis	Anemia, anxiety/hyperventilation, deconditioning

Initial Stabilization

• O₂ to target SpO₂ 92–96% (88–92% if COPD/hypercapnic risk).
• NIV (BiPAP) for COPD/COPD exacerbation, cardiogenic pulmonary edema.
• Nebulized bronchodilators (asthma/COPD).
• IV diuretics (acute HF).
• Anticoagulation (high prob PE).
• Needle decompression (tension pneumothorax).

Disposition: Admit (ICU/step-down/floor) vs. discharge with close follow-up based on etiology, response, social support.