A p p ro a c h t o A d u l t Pa t i e n t s

with Acute Dyspnea

Elizabeth DeVos, MD, MPH, Lisa Jacobson, MD*

KEYWORDS
 Dyspnea  Shortness of breath  Asthma  COPD  Respiratory compensation
 Pneumonia  Pulmonary embolism  Angina

KEY POINTS
 The cause of dyspnea is often evident from a complete history and physical examination.
 Rapid determination of the cause of dyspnea saves lives.
 Shortness of breath is not always primarily a pulmonary problem.
 Understanding the pathophysiology of each disease allows clinicians to make rational de-
cisions about testing.

INTRODUCTION

Emergency Medical Services (EMS) calls en route with a 45-year-old woman who has
a history of congestive heart failure, chronic bronchitis, morbid obesity, and diabetes.
She is breathing 40 times per minute, maintaining oxygen saturations of 94%. She ap-
pears mildly confused. You have 5 minutes to consider algorithms before the patient
arrives. Perhaps respiratory therapy is paged to supply a ventilator or a biphasic pos-
itive airway pressure (BIPAP) machine. Maybe you prepare airway equipment or ask
your nursing staff to access medication in advance, or you might use the time to
expand your differential and determine what brief information regarding the patient’s
history and initial physical examination will help you treat her.
Acutely dyspneic patients present in various ways. Are the lungs full of fluid or pus?
Did the throat swell shut or is the patient just anxious? Did the patient aspirate a
foreign body or have a slow or rapid hemorrhage? Is the patient compensating for a
severe metabolic acidosis or did the patient run out of beta agonists at home? This
article provides helpful guidelines in the assessment and management of these
diverse patients.

Disclosures: None.
Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville,
655 West 8th Street, Jacksonville, FL 32209, USA
* Corresponding author.
E-mail address: [email protected]

Emerg Med Clin N Am 34 (2016) 129–149

http://dx.doi.org/10.1016/j.emc.2015.08.008 emed.theclinics.com
0733-8627/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
130 DeVos & Jacobson

Respiratory distress is responsible for nearly 4 million emergency department (ED)

visits each year and is one of the most common presenting complaints in the elderly.1
When a patient presents with dyspnea, the primary task of the emergency physician is
to assess for and ensure stability of the patient’s airway, breathing, and circulation. In
the case of dyspnea, presentations may range from minor symptoms to extremis.
Rapid assessment may necessitate the use of intubation, BIPAP, nebulizations,
decompression, or other therapies in the immediate period following the patient’s
arrival, to treat dyspnea.

PATIENT EVALUATION

The American Thoracic Society suggests that “dyspnea results from a . mismatch
between central respiratory motor activity and incoming afferent information from re-
ceptors in the airways, lungs and chest wall structures.”2 This dissociation can result
from increased metabolic demand, decreased compliance, increased dead-space
volume, or many other disorders that are discussed later. Each patient presenting
short of breath uses a different set of phrases to describe the symptoms and exami-
nation reveals a different combination of disorders. The clinician’s ability to interpret
these varying constellations is necessary to provide appropriate treatment to these
patients, who are often in serious distress.

History
Acute dyspnea, or shortness of breath, is one of the most common chief complaints in
the ED. The differential diagnosis includes many disorders that can be divided based
on obstructive, parenchymal, cardiac, and compensatory features. A careful history
can begin to narrow this wide differential. In addition to common symptoms, consider
risk factors such as past medical and family history, trauma, travel, medications, and
exposures.
Schwartzstein and Lewis3 use the analogy of a machine to identify different causes
of dyspnea based on pathophysiologic data. Dysfunctions of the respiratory system
may be caused by faulty controllers, ventilatory pumps, or gas exchangers
(Table 1). This table makes it easier to understand the causes of shortness of breath
related to respiratory causes.
Cardiovascular disease manifests as dyspnea by causing disruptions of the system
that pumps oxygenated blood to tissues and then transports the carbon dioxide back
to the lung. Decreases in cardiac output or increases in resistance limit oxygen deliv-
ery. Similarly, decreased oxygen carrying capacity in anemia plays a role in its presen-
tation with dyspnea.

Physical Examination
A detailed physical examination also provides important guidance (Table 2). Respira-
tory rate and oxygen saturation are obtained with vital signs. The clinician should
assess the patient’s work of breathing, looking for any tripoding or retractions. Crep-
itance in the chest may indicate subcutaneous air and pneumothorax. Lung sounds
such as wheezing, rales, and rhonchi further guide the differential. Decreased sounds,
hyperresonance, or egophony may also provide additional clues.
Jugular venous distension, S3 gallop, and peripheral edema indicate that a patient
has fluid overload. Conjunctival pallor, capillary refill, and temperature of extremities
can provide clues about blood volume and general circulation. Pulses must also be
assessed.
 Adult Patients with Acute Dyspnea 131

Table 1
A systemic approach to dyspnea by assessing the components of the respiratory process

Part Description Manifestations Examples

Controller Malfunction presents as abnormal Air hunger, need Abnormal feedback to
respiratory rate or depth. Often to breathe brain from other
related to abnormal feedback to systems. Metabolic
brain from other parts of the acidosis, anxiety
system
Ventilatory Composed of muscles, nerves that Increased work Neuromuscular problems
pump signal the controller, chest wall, of breathing, (eg, Guillain-Barré),
and pleura that create negative low tidal decreased chest wall
thoracic pressure, airways and volumes compliance,
alveoli allowing flow from pneumothorax,
atmosphere and gas exchange pneumonia,
bronchospasm
(COPD, asthma)
Gas Oxygen and carbon dioxide cross Increased Emphysema, pneumonia,
exchanger the pulmonary capillaries in the respiratory pulmonary edema,
alveoli. Membrane destruction drive, pleural effusion,
or interruption of the interface hypoxemia, hemothorax
between the gas and capillaries chronic
by fluid or inflammatory cells hypercapnia
limit gas exchange

Adapted from Schwartzstein RM, Lewis A. Dyspnea. In: Broaddus V, Mason RC, Ernst JD, et al, ed-
itors. Murray & Nadel’s textbook of respiratory medicine. Elsevier health sciences. 6th edition. Phil-
adelphia: Saunders/Elsevier; 2015.

Testing
Multiple tests are available to narrow the differential diagnosis of acute dyspnea. When
using tests to augment clinical decision making, be sure to weigh the information they
may provide with any risks involved in performing the tests (Table 3).
Ultrasonography provides valuable information about the origin of symptoms,
and, often, diagnosis in the initial assessment of an acutely dyspneic patient. These
images may be obtained during or shortly after initial assessment, potentially

Table 2
Physical examination findings and correlating diagnoses

Symptom Differential Diagnosis

Wheeze COPD/emphysema, asthma, allergic reaction, CHF (cardiac wheeze)
Cough Pneumonia, asthma, COPD/emphysema
Pleuritic chest pain Pneumonia, pulmonary embolism, pneumothorax, COPD, asthma
Orthopnea Acute heart failure
Fever Pneumonia, bronchitis, TB, malignancy
Hemoptysis Pneumonia, TB, pulmonary embolism, malignancy
Edema Acute heart failure, pulmonary embolism (unilateral)
pulmonary edema Acute and chronic heart failure, end stage renal and liver diseases, ARDS
(sepsis)
Tachypnea alone pulmonary embolism, acidosis (including aspirin toxicity), anxiety

Abbreviations: ARDS, acute respiratory distress syndrome; CHF, congestive heart failure; COPD,
chronic obstructive pulmonary disease; TB, tuberculosis.
132 DeVos & Jacobson

Table 3
Diagnostic testing for dyspneic patients

Test General Information Pros Cons

Chest radiograph Often primary Low radiation, can Low sensitivity in acute
imaging assess consolidation, dyspnea. In one series
pleural fluid, only 8 of 26
hyperinflation, pneumonias
pneumothorax, and diagnosed on CT met
subcutaneous air. CXR criteria37
Heart size is apparent
Ultrasonography Multiple protocols to No radiation, fast, Requires some skill to
assess acute reproducible bedside acquire and interpret
dyspnea test, can be done on bedside images.
unstable patients in Patient factors such as
department and in subcutaneous air,
semirecumbent body habitus, and so
position forth may limit images
D-dimer Marker of fibrinolytic Serum test readily Requires risk assessment
activity. When available and clear clinical
measured by ELISA question. Also
or second- increased in
generation latex consumptive
agglutination can coagulopathy,
be used to rule out infection, malignancy,
PE in selected trauma, dissection,
patients preeclampsia, and
other cardiovascular
disorders
Arterial blood gas Provides additional May be faster than Limited evidence for
information about general laboratory routine use in
ventilation (PaCO2) tests. Useful in undifferentiated
to patients with assessing dyspnea
reliable pulse anxiety-induced
oximetry and hyperventilation36
bicarbonate level
available on BMP
Electrocardiogram Initial cardiac Fast and inexpensive. May be nonspecific in
assessment for Easy to compare with findings such as right
assessing dyspnea prior examinations. heart strain and P
Specific for pulmonale
dysrhythmias or ACS
limiting perfusion
Troponin Serum indicator of Serum test readily Can narrow differential
myocardial damage available to cardiac causes. PE
with right heart strain
may have increased
troponin levels; this
finding predicts worse
outcomes
BNP and proBNP Useful in assessing for Serum test readily Limited in obesity, mitral
acute heart failure available regurgitation, flash
pulmonary edema,
and renal
insufficiency. Context
is essential

(continued on next page)

 Adult Patients with Acute Dyspnea 133

Table 3
(continued )
Test General Information Pros Cons
Complete blood Provides information Serum test readily Nonspecific
count about oxygen available
carrying capacity
based on
hemoglobin and
hematocrit. White
blood cell count
may indicate
infection
CT scan Provides detailed Offers sensitive and Significant radiation
imaging of specific results exposure, contrast
cardiorespiratory nephropathy,
system. Use is intravenous contrast
increasing, but dye reactions
practitioners should
maintain clinical
context and
consider whether
other modalities
can answer the
clinical question
Ventilation/ Radiolabeled aerosol Low in radiation Limited by underlying
perfusion scan and albumin pulmonary disease
aggregates are used and availability of
to study ventilation isotopes
and perfusion. Read
as negative or low,
medium or high
probability for
pulmonary
embolism

Abbreviations: ACS, acute coronary syndrome; BMP, basic metabolic panel; BNP, B-type natriuretic
peptide; CT, computed tomography; CXR, chest radiograph; ELISA, enzyme-linked immunosorbent
assay; proBNP, pro–B-type natriuretic peptide.

guiding therapy faster than laboratory tests or other imaging studies would be avail-
able. The Bedside Lung Ultrasonography in Emergency (BLUE) protocol offers one
approach to differentiate several causes of respiratory failure (Table 4 and
Figs. 1–9).
Other protocols include assessments to assess for other cardiac causes of dys-
pnea.4–6 Focused evaluation of global left ventricular function, diastolic function, right
ventricular size, and any pericardial effusion facilitates rapid assessment for massive
myocardial infarction, cardiac tamponade, and massive pulmonary embolism at the
bedside. In addition, inferior vena cava measurement can be used to assess for
right-sided heart failure and to estimate central venous pressure.
Computed tomography (CT) use to evaluate acute dyspnea has increased in the last
decade.7 Risks include contrast reactions and nephropathy as well as radiation-
induced cancers.8 Recent American College of Physicians recommendations advo-
cate avoidance of CT as an initial test to evaluate patients at low risk for pulmonary
embolism (PE).9 Further, nearly one-fourth of patients undergoing CT for PE evaluation
 134
Table 4

DeVos & Jacobson

BLUE protocol

Ultrasonography Ultrasonography
Finding Approach Description Clinical Meaning Image
Assess for Anterior Subpleural air causes repeated linear artifacts Air in lung: either normal or pneumothorax Fig. 1
artifacts: A parallel to the pleural line (horizontal)
lines
Assess for Anterior Seven features: hyperechoic, well-defined, Represents an interface of 2 widely different Fig. 2
artifacts: B hydroaeric comet-tail artifacts arising from the transmissions of ultrasound waves: in this case,
lines pleural line. They spread upwards indefinitely air and fluid. When 3 or more B lines are in a
and obscure A lines. When lung sliding is single interspace, they are B1 lines (or
present, they move with the lung pulmonary rockets), indicating interstitial
syndrome
Assess for lung Anterior Absence of lung sliding occurs with a disruption of Absence of lung sliding in the presence of A lines Fig. 3
sliding the normal sliding of viscera on parietal pleura necessitates search for pneumothorax. Lung (stratosphere
or separation of the two. In M mode, absence of point is the ultrasonography finding in which sign)
lung slide is seen as the stratosphere sign (also lung slide is seen in the same view with the Fig. 4 (normal
known as bar-code sign) abolished lung slide and A lines in the same lung)
location, indicating the tip of the lung Fig. 5 (lung
point)
Assess for Lateral The classic anechoic, dependent pattern may be Pleural effusion: sinusoid, plus may have quad Figs. 6 and 7
alveolar subposterior inconsistent. Other findings include (1) quad sign. Alveolar consolidation: tissuelike (pleural
consolidation sign: pleural effusion on expiration noted appearance or shred sign, absent lung line, effusion)
or pleural between the pleural and regular, lower lung absent sinusoidal sign Fig. 8
effusion lines (viscera). (2) Shred sign: tissuelike pattern (tissuelike
(posterolateral seen with alveolar consolidation, with the upper lung)
alveolar and/or border of lung line (or pleural line when there is Fig. 9
pleural no effusion) with an irregular lower border. (3) (sinusoidal)
syndrome) Sinusoid sign: movement of the lung line
toward the pleural line in inspiration
Deep venous Femoral veins Visualization of thrombus in the lumen or lack of Consider pulmonary embolus if positive —
thrombosis compressibility is positive test

Adapted from Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest 2008;134(1):117–25;
and Courtesy of Petra Duran, MD, RDMS, University of Florida College of Medicine-Jacksonville (FL).
 Adult Patients with Acute Dyspnea 135

Fig. 1. A lines.

have clinically significant incidental findings. Although CT may provide vital diagnostic
information, clinicians must not only consider the scan’s necessity but also plan
appropriate follow-up for any clinically important incidental findings.10 Always
consider whether CT is necessary or whether less risky modalities, such as chest
radiograph or ultrasonography, will answer pertinent questions.

Fig. 2. B lines.
136 DeVos & Jacobson

Fig. 3. Stratosphere sign.

DIFFERENTIAL DIAGNOSIS FOR ACUTELY DYSPNEIC PATIENTS

Obstructive Dyspnea
Consider the 35-year-old woman discussed earlier. Medics report tachypnea with
very poor air movement during transport. As she rolls through the ambulance bay
doors, you are already assessing her. Adept clinicians can spot respiratory distress
from across the room. She is diaphoretic, her shoulders are held adjacent to her
ears, and she is breathing extremely rapidly with minimal air movement. You decide

Fig. 4. Normal lung.

 Adult Patients with Acute Dyspnea 137

Fig. 5. Lung point.

to aggressively treat her for a severe asthma exacerbation, starting BIPAP ventilation
with continuous nebulized albuterol and order adjunct therapies including intravenous
steroids, intravenous magnesium, and intramuscular epinephrine. After 20 minutes at
her bedside, she begins to breathe more comfortably with the BIPAP machine and
repeat auscultation reveals diffuse wheezing and improved air movement.

Fig. 6. Pleural effusion.

138 DeVos & Jacobson

Fig. 7. Pleural effusion.

As she begins to improve, EMS returns with another patient. His breath sounds are
audible to everyone in the resuscitation bay. He appears diaphoretic and panicked.
Examination reveals stridor, periorbital edema, tachycardia, and hypotension. Imme-
diate intervention for anaphylactic shock begins and, after 2 rounds of epinephrine,
fluid boluses, antihistamines, and steroids, he too begins to look better.
Wheezing, or musical respiratory sounds, typically result from partial airway obstruc-
tion.11 Because this obstruction can result from inflammation, secretions, or even a
foreign body, patients with noisy or whistling breathing need close evaluation to

Fig. 8. Tissuelike lung.

 Adult Patients with Acute Dyspnea 139

Fig. 9. Sinusoidal sign.

determine whether the noise is inspiratory or expiratory, and whether it is from the
lower airways or the upper airways. Stridor from a swollen airway, foreign body, or
other airway obstruction is imminently dangerous. Although patients in anaphylaxis
may benefit from the nebulized beta-agonist treatment used to treat an asthma exac-
erbation, it is not sufficient to save their lives. As opposed to wheezing, which is a lower
airway expiratory sound, stridor is an upper airway sound transmitted when there is
obstruction to the inflow of air during inspiration. The obstruction may be fixed (food
bolus; Fig. 10) or inflammatory (anaphylaxis), but in any situation must be emergently
managed.
National and world organizations define asthma “by the history of respiratory symp-
toms such as wheeze, shortness of breath, chest tightness and cough that vary over
time and in intensity, together with variable expiratory airflow limitation.”12 The revers-
ibility of airflow obstruction is the hallmark distinguishing asthma from other obstruc-
tive respiratory disorders. In contrast, chronic obstructive pulmonary disease (COPD)/
emphysema is defined as “persistent airflow limitation that is usually progressive and
associated with enhanced chronic inflammatory responses in the airways and the
lungs.”12 These patients also frequently wheeze, but may have a different course of
acute and chronic disease. Table 5 highlights the differences between these similar,
at times overlapping, diseases.
Asthma is an obstructive disease resulting from increased airway resistance. It is a
reversible but recurrent chronic inflammatory disorder that characteristically causes
severe dyspnea, wheezing, and coughing.13 There are 2 main problems in asthma:
chronically inflamed airways and hyperresponsive airways. Intermittent airflow
obstruction in symptomatic patients results in decreased ability to expire, leading to
hyperinflation, stenting open the alveoli, and increasing the work of breathing. Early
in an exacerbation, symptoms are bronchospastic secondary to smooth muscle
contraction. As an episode progresses, inflammatory changes in the airways can
cause increased airway resistance and lead to VQ mismatch (Fig. 11). The severity
of an exacerbation can be assessed clinically and should dictate how aggressively
a patient is treated (Table 6).
140 DeVos & Jacobson

Fig. 10. Food bolus in airway.

COPD is defined by the Global Initiative for Chronic Obstructive Lung Disease
(GOLD) as “persistent airflow limitation that is usually progressive and associated
with an enhanced chronic inflammatory response in the airways and the lung to
noxious particles or gases.”12 The pathophysiology in each patient is typically a mix
of lung parenchymal destruction, as seen in emphysema, and small airway inflamma-
tion with airway obstruction, or obstructive bronchiolitis.11 An exacerbation of COPD
presents as dyspnea, cough, and increased sputum production. In the emergent

Table 5
Features suggesting asthma or COPD

Favors Asthma Favors COPD

Onset in childhood Onset in adulthood
Symptoms vary over time Symptoms persist even with treatment
Symptoms worse at night Daily symptoms, some days better than others
Symptoms may be triggered by allergens Chronic cough and sputum unrelated to triggers
or exercise
Variable airflow obstruction Persistent airflow obstruction
Normal lung function when asymptomatic Abnormal lung function when asymptomatic
Atopy in self or family Smoker
No progression over time Progression over time

Adapted from Global Initiative for Asthma. Diagnosis of diseases of chronic airflow limitation:
asthma, COPD and asthma-COPD overlap syndrome (ACOS). 2015. Available at: http://www.
ginasthma.org/documents/14/Asthma%2C-COPD-and-Asthma-COPD-Overlap-Syndrome-%28AC
OS%29. Accessed May 1, 2015.
 Adult Patients with Acute Dyspnea 141

Fig. 11. Pathophysiology of symptom development in asthma.

setting, clinicians must treat the airflow limitation. As with asthma, monitoring of pulse
oximetry, degree of respiratory distress, and hemodynamic stability can help clinicians
anticipate the degree of severity of a particular exacerbation. More specific testing
may also have a role, because radiographs and electrocardiograms may help differen-
tiate other causes of shortness of breath from a COPD exacerbation. In addition, an
increase in sputum production or the presence of purulent sputum should be treated
with antibiotics, regardless of other infectious symptoms.14
Anaphylaxis is a sudden, potentially fatal, allergic reaction involving multiple organ
systems.15,16 The Second Symposium on the Definition and Management of Anaphy-
laxis lists the following clinical criteria for diagnosis of anaphylaxis:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin,
mucosal tissue, or both (eg, generalized hives; pruritus or flushing; swollen lips,
tongue, uvula)
And at least 1 of the following:
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor,
reduced peak expiratory flow, hypoxemia)

Table 6
Severity of asthma exacerbation assessment

Symptoms Mild Moderate Severe Near Death

Breathless While walking While talking At rest Decreased effort
Speaking In sentences In phrases In words Unable
Alertness May be agitated Usually agitated Usually agitated Confused
Respiratory Rate Increased Increased >30 >30, imminent
(breaths/min) failure
Accessory Muscle Use Usually not Commonly Usually Usually
Wheeze Moderate Loud Loud or silent Silent
Heart Rate (beats/min) <100 100–120 >120 
Saturation (%) >95 92–94 <90 <90
142 DeVos & Jacobson

b. Reduced blood pressure (BP) or associated symptoms of end-organ dysfunc-

tion (eg, hypotonia [collapse], syncope, incontinence)
2. Two or more of the following that occur rapidly after exposure to a likely allergen for
that patient:
a. Involvement of the skin-mucosal tissue
b. Respiratory compromise
c. Reduced BP or associated symptoms
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
3. Reduced BP after exposure to known allergen for that patient:
a. Infants and children: low systolic BP (age specific) or greater than 30%
decrease in systolic BP
b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from
that person’s baseline
It is the respiratory compromise that is relevant to this article, and it is important to
recognize that treating the allergic component of these symptoms is necessary to
save the patients.

Parenchymal Dyspnea
Now EMS is at the back door with a 60-year-old patient with a history of COPD and
congestive heart failure (CHF). He is in respiratory distress with audible wheezing
and tripoding. He is diaphoretic, hypertensive, and has pitting edema to his knees.
They have given albuterol with no improvement of his symptoms.
Acute dyspnea is the most common symptom of patients presenting with heart fail-
ure.17 Eighty percent of patients with acutely decompensated heart failure present
through the ED with a chief complaint of dyspnea.18 This symptom is related to
both pulmonary and systemic fluid overload and also low cardiac output. American
College of Emergency Physicians clinical policy makes level B recommendations
that standard clinical judgment can be improved with the use of a single B-type natri-
uretic peptide (BNP) or N-terminal pro–B-type natriuretic peptide measurement to rule
in or out the diagnosis of CHF.19 However, the true utility, may be in patients with dys-
pnea not expected to have a CHF exacerbation, when finding a positive BNP would
change management and allow a faster initiation of treatment.20
Carpenter and colleagues20 found that the classic constellation of symptoms (ju-
gular venous distension, peripheral edema, rales, and S3) were no more predictive of
patients with both pulmonary edema on chest radiograph and an increased BNP
level greater than 500 pg/dL than any individual finding alone. Although rales were
the most sensitive finding tested for either outcome, they had specificity of only
about 50% each. Jugular venous distention and S3 gallop were the individual find-
ings most predictive for pulmonary edema on radiograph or increased BNP level. Ul-
trasonography measurements of the inferior vena cava also improve diagnostic
accuracy versus BNP and chest radiograph alone.21
The medics are back in your department, this time with a 75-year-old man with
cough and fever. His family is worried that he has been eating less and is sleepier
than at hospital discharge last week. In pneumonia, the diffusion of oxygen is limited
by alveolar infiltrates, leading to shortness of breath. Common complaints and find-
ings in community-acquired pneumonia include fever, cough, pleuritic chest pain,
and sputum production, along with dyspnea. However, these clinical criteria may
have a sensitivity as low as 50% compared with a chest radiograph.22 On examina-
tion, many patients have crackles or evidence of consolidation. Guidelines from the
Infectious Diseases Society of America and the American Thoracic Society,
 Adult Patients with Acute Dyspnea 143

recommend chest radiograph in patients with suspected pneumonia, which may show
lobular consolidation, interstitial infiltrate, or cavitation.23 Although infiltrate with sug-
gestive symptoms makes the diagnosis, infiltrate may not be visible initially on patients
with volume depletion. It is appropriate to treat empirically for 24 to 48 hours in these
cases and to reimage when hydration is restored.
The management of pneumonia requires history to allow classification based on the
setting in which the illness was acquired. The Infectious Disease Society of America
and American Thoracic Society define the types of pneumonia as follows:24Hospital-
acquired pneumonia (HAP) is “pneumonia that occurs 48 hours or more after admis-
sion which was not incubating at the time of admission.” Ventilator-associated
pneumonia (VAP) arises “more than 48-72 hours after endotracheal intubation.” In
addition, health care–associated pneumonia (HCAP) is diagnosed in any patient who
is “hospitalized in an acute care hospital for two or more days within 90 days of the
infection, resided in a nursing home or long-term care facility, received recent IV anti-
biotic therapy, chemotherapy or wound care within the past 30 days of the current
infection or attended a hospital or hemodialysis clinic.” Community-acquired pneu-
monia is not acquired in any of these situations. These classifications identify typical
pathogens and guide appropriate initial management. Important historical exposures
and risk factors to refine treatment are summarized in Table 7.23
The American Thoracic Society along with the Infectious Disease Society of Amer-
ica’s consensus statement offers 4 important principles in the initial management and
evaluation of adult patients with bacterial HAP, VAP, or HCAP; the most important to
be accomplished in the ED is to promptly treat with “appropriate and adequate ther-
apy” to decrease mortality.24

Circulatory Dyspnea
After a brief delay, you see a 28-year-old woman with shortness of breath and chest
pain. She smokes, uses hormonal birth control, and reports that her symptoms
started when she came back from a business trip. Pulmonary embolism (PE) inter-
feres with both ventilation and perfusion. It ultimately causes circulatory collapse
because of obstruction of right ventricular outflow eventually causing increased pul-
monary artery pressure and failure of the right then left ventricles. Before circulatory
collapse, echocardiography can show signs of right ventricular (RV) strain, including
dilatation of the right ventricle, RV hypokinesis, paradoxic septal wall motion,
McConnell sign (hypokinesis of the free RV wall with sparing of the apex), and
tricuspid regurgitation.25
Dresden and colleagues26 supported the use of ultrasonography in moderate-risk to
high-risk patients to determine whether the patients were appropriate for anticoagu-
lation while awaiting definitive imaging. Early anticoagulation is recommended to
improve mortality and there is evidence to support anticoagulation before diagnosis
in patients with a Wells score greater than 4 who will have a delay to diagnosis of
more than 1 hour and 40 minutes.27,28
The assessment of patients with dyspnea and concern for PE requires a series of
risk stratification. One common method is to use Wells criteria29 (Box 1) in patients
with suspicion for PE; although other stratification tools exist, none has been shown
to be clearly superior. When there is low clinical suspicion for PE, PERC (pulmonary
embolism rule-out criteria)30 rules or D-dimer testing may be applied.27 If PERC
(Box 2) is negative, or there is intermediate pretest probability for PE with negative
high-sensitivity D-dimer, no further testing for PE is required.27 When further testing
is needed (positive D-dimer or high-sensitivity D-dimer not available), negative CT
angiogram or low-probability VQ scan may be used to rule out PE.
144 DeVos & Jacobson

Table 7
Common pathogens in community-acquired pneumonia

Condition Commonly Encountered Pathogens

Alcoholism Streptococcus pneumoniae, oral anaerobes, Klebsiella
pneumoniae, Acinetobacter species, Mycobacterium
tuberculosis
COPD and/or smoking Haemophilus influenzae, Pseudomonas aeruginosa,
Legionella species, S pneumonia, Moraxella
catarrhalis, Chlamydophila pneumoniae
Aspiration Gram-negative enteric pathogens, oral anaerobes
Lung abscess CA-MRSA, oral anaerobes, endemic fungal pneumonia,
M tuberculosis, atypical mycobacteria
Exposure to bat or bird droppings Histoplasma capsulatum
Exposure to birds Chlamydophila psittaci (if poultry: avian influenza)
Exposure to rabbits Francisella tularensis
Exposure to farm animals or Coxiella burnetii (Q fever)
parturient cats
HIV infection (early) S pneumoniae, H influenzae, M tuberculosis
HIV infection (late) The pathogens listed for early infection plus
Pneumocystis jirovecii, Cryptococcus, Histoplasma,
Aspergillus, atypical mycobacteria (especially
Mycobacterium kansasii), P aeruginosa, H influenzae
Hotel or cruise ship stay in previous Legionella species
2 wk
Travel to or residence in Coccidioides species, Hantavirus
southwestern United States
Travel to or residence in southeast Burkholderia pseudomallei, avian influenza, SARS
and east Asia
Influenza active in community Influenza, S pneumoniae, Staphylococcus aureus, H
influenzae
Cough>2 wk with whoop or Bordetella pertussis
post-tussive vomiting
Structural lung disease (eg, P aeruginosa, Burkholderia cepacia, S aureus
bronchiectasis)
Injection drug use S aureus, anaerobes, M tuberculosis, S pneumoniae
Endobronchial obstruction Anaerobes, S pneumonia, H influenzae, S aureus
In context of bioterrorism Bacillus anthracis (anthrax), Yersinia pestis (plague),
Francisella tularensis (tularemia)

Abbreviations: CA-MRSA, community-acquired methicillin-resistant Staphylococcus aureus; HIV,

human immunodeficiency virus; SARS, severe acute respiratory syndrome.
From Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/
American Thoracic Society consensus guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis 2007;44(Suppl 2):S46; with permission.

In the next bed is a middle-aged woman with diabetes complaining of shortness of

breath today. It was associated with some vague nausea and she says that she just
does not feel good. Angina pectoris is cardiac chest pain in which oxygen demand
outweighs myocardial oxygen supply; in this case caused by occlusion of coronary
arteries. Although typically chest pain is a part of the presentation, dyspnea alone
may be the initial complaint, termed an anginal equivalent. In one recent large series
of patients undergoing stress testing, patients with dyspnea alone were at increased
 Adult Patients with Acute Dyspnea 145

Box 1
Wells criteria for pulmonary embolism

 Clinical signs and symptoms of deep vein thrombosis (DVT): 13

 PE is the main diagnosis or equally likely: 13
 Heart Rate greater than 100 beats/min: 11.5
 Immobilization >3 days or surgery in last 4 weeks: 11.5
 History of prior PE/deep venous thrombosis (DVT): 11.5
 Hemoptysis: 11
 Malignancy with treatment within 6 months or palliative: 11

Less than or equal to 1.5 5 low risk, 1.3% chance of PE in ED population; 2 to 6 5 moderate risk,
16.2% chance of PE in ED population; greater than 6 5 high risk, 40.6% chance of PE in ED
population
Adapted from Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the
bedside without diagnostic imaging: Management of patients with suspected pulmonary em-
bolism presenting to the emergency department by using a simple clinical model and D-dimer.
Ann Intern Med 2001;135:99.

risk of death from cardiac causes. Patients asked simply whether they experienced
shortness of breath were considered dyspneic. The subset with no prior known cor-
onary artery disease had more than 4 times the risk of sudden cardiac death versus
asymptomatic patients and more than twice the risk of those with typical angina.31
Clinicians should consider past medical history and risk factors when assessing dys-
pnea for cardiac causes such as acute myocardial infarction and acute coronary syn-
drome. Appropriate testing includes bedside electrocardiogram, troponin, and chest
radiograph.
The department eventually settles down and you are able to do some charting until a
young man comes in with visible respiratory distress. He is tall and thin, smokes regu-
larly, and reports sudden onset of severely painful breathing. Pneumothorax occurs
when air enters the plural space between the chest wall and the lung. Typically only
a thin serous layer exists between the visceral and parietal pleura. Air enters this po-
tential space only when there is damage to the lung or chest wall, or a gas-producing
pleural space infection. The classic risk factors for bleb rupture causing spontaneous

Box 2
Pulmonary embolism rule-out criteria

 Further work-up recommended if any of the following are present:

 Age greater than or equal to 50 years
 Pulse greater than or equal to 100 beats/min
 Oxygen saturation less than 95%
 Hemoptysis
 Unilateral leg swelling
 History of PE/DVT
 Exogenous estrogen use
 Surgery or trauma within 4 weeks that required hospitalization or intubation
 If none are present, probability of PE is less than 2%.

Adapted from Kline JA, Courtney DM, Babrhel C, et al. Prospective multicenter evaluation of
the pulmonary embolism rule-out criteria. J Thromb Haemost 2008;6(5):773.
146 DeVos & Jacobson

pneumothorax are tall men, although smoking has been suggested to increase the risk
of rupture by damaging the pleural layer.
Pneumothoraces may be identified by ultrasonography, chest radiograph, or CT.
Treatment may be guided by cause, severity, comorbidities, interventions such as
positive pressure ventilation, size of the pneumothorax, and patient’s preference.
Recent studies suggest that uncomplicated spontaneous pneumothorax in patients
not undergoing positive pressure ventilation may be treated as successfully with nee-
dle aspiration as with other more invasive chest drains, regardless of size.32
Tension pneumothorax is a serious event requiring immediate needle decompres-
sion to avert loss of cardiac output and arrest. However, recent review shows that
the classic presentation of tension pneumothorax with hypotension, absent breath
sounds, and deviated trachea may not be immediately seen in patients with sponta-
neous, unassisted respiration.33 Because of the slower development of the accumu-
lation of air and pressure variations, spontaneously breathing patients may
compensate much longer and present atypically, as shown in Table 8. Thus, clinicians
must remain vigilant.

Compensatory Dyspnea
This article focuses on the cardiopulmonary system as the source of the problem in
acutely dyspneic patients. It is important to also consider that the appearance of
shortness of breath, tachypnea, or other typical symptoms of dyspnea may result
from changing metabolic demands. These patients may appear, on the surface, to
be in respiratory distress; they may be tachypneic, tachycardic, even pale or diapho-
retic. In these cases, the clinician’s responsibility is to identify and fix the true problem
in order to improve the respiratory symptoms.
Severely anemic patients have limited oxygen carrying capacity. Their bodies there-
fore experience oxygen hunger, which can manifest as shortness of breath. Patients
with dysfunctional hemoglobins secondary to irreversibly bound atoms or toxins
may also be functionally anemic with the same symptoms.
People’s bodies attempt at all costs to maintain equilibrium. Therefore, in metabolic
acidoses (such as diabetic ketoacidosis), chemoreceptors detect acidosis and

Table 8
Findings in tension pneumothorax

Unassisted Ventilation Positive Pressure Ventilation

Spontaneous respiration with air passing Assisted ventilation forces air through pleural
through 1-way flap defect into pleural space
Compensatory mechanisms delay collapse: Sudden hemodynamic and respiratory
 Tachycardia and accessory muscle use compromise:
caused by tachypnea, increased tidal vol-  Sedation may increase inspiratory pressure
ume, and negative movement of the oppo-  Intrapleural pressure is increased
site side of the chest throughout respiratory cycle
 BP is maintained because of limits in the
pressure of the pneumothorax on medias-
tinum and hemithorax
Venous siphon resulting from negative Decreased venous return leads to hypotension
intrathoracic pressure in the opposite side and cardiac arrest
of the chest returns blood to the heart

Adapted from Roberts DJ, Leigh-smith S, Faris PD, et al. Clinical presentation of patients with ten-
sion pneumothorax: a systematic review. Ann Surg 2015;261(6):1069.
 Adult Patients with Acute Dyspnea 147

stimulate the respiratory center to hyperventilate. Both the rate and the depth of venti-
lation often increase, leading to both tachypnea and hyperpnea, at times referred to as
Kussmaul respirations. This compensatory response is crucial for survival and should
not be mistaken for dyspnea. It is equally important to realize that an increase in alve-
olar ventilation is not always a compensatory response (to acidosis or to primary pul-
monary disorders) and hypocapnia may cause primary respiratory alkalosis, from
central nervous system compromise, toxins (eg, salicylates), anxiety, or pain.34 In
these patients, imaging rarely reveals a source of dyspnea, but clinical suspicion
based on history and examination, including signs such as the fruity breath of ketone-
mia, the pallor of anemia, or the cyanosis of toxic hemoglobinopathies, directs pro-
viders toward appropriate laboratory testing and treatment.
Diagnosis of Exclusion
In addition, sometimes dyspnea is not dyspnea. Acute anxiety and panic disorder can
present as shortness of breath, tachypnea, or hyperventilation. Patients with panic
disorder often describe symptoms similar to those of patients with true airway
obstruction despite their normal pulmonary function. It has been suggested that these
patients have abnormal proprioception, experiencing dyspnea without abnormal stim-
uli.35 However, patients with a history of pulmonary disease can also have pure panic
episodes. Arterial blood gas may be useful in diagnosing anxiety-related
hyperventilation.36
Severe pain can also induce abnormal respiratory patterns. Like compensatory
problems, pain and anxiety can be managed by managing their causes. Treat pain.
Reduce stress and anxiety with words, behaviors, or, if necessary, medications. How-
ever, air hunger and difficulty breathing also make individuals anxious. Be sure to
avoid premature diagnosis of a purely anxiety-based concern without first evaluating
for more dangerous disorders.

SUMMARY

Acute dyspnea presents commonly to the ED and it is imperative that emergency phy-
sicians be prepared to stabilize patients’ oxygenation and ventilation, which requires
careful and efficient consideration of the differential diagnosis. Using cues from the
history and physical examination, practitioners may guide the work-up and treatment
to identify a parenchymal, obstructive, circulatory, or compensatory cause of dys-
pnea. Early use of bedside testing, including ultrasonography, may limit unnecessary
tests and save time in determining the best treatment course. Thus ensuring both the
best care for the patient and also the physician’s ability to readily respond to the next
case.

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