Dyspnea
at the bedside
- airway, breathing, circulation; full vitals, cardiac monitor, continuous SpO₂; sit the patient up; why admitted, what changed, baseline O₂ requirement
- oxygen → to target 90–94%, 88–92% if at risk of hypercapnia; titrate; do not withhold it from a distressed patient while waiting for a number; targets pending the gas → oxygen desaturation
- distress with a normal number → severe distress despite an acceptable SpO₂, especially on oxygen, is still an emergency: work of breathing, fatigue, consciousness and ventilation count → respiratory rate
- listen to both sides → unequal air entry, wheeze, crackles, stridor; look at the neck veins and the legs
- chart and lines → IV fluids running, recent transfusion, new drug, opioid or sedative, inhaler or diuretic missed
- ECG and a gas if unwell or the cause is not obvious
escalate now if
- stridor, angioedema, or wheeze with rash or hypotension → upper airway / anaphylaxis
- absent breath sounds one side with hypotension or tracheal deviation → tension pneumothorax
- muffled heart sounds, distended neck veins, hypotension → cardiac tamponade
- sudden dyspnea with syncope, shock or RV strain → high-risk PE
- tearing chest pain or arm BP difference > 20 mmHg → aortic dissection
- silent chest, drowsy, exhausted or rising CO₂ → severe asthma / COPD, ICU now
- SpO₂ < 90% despite oxygen, RR > 30, severe work of breathing or fatigue at any SpO₂, or reduced consciousness → respiratory support
- hypotension or shock → hypotension
differentials
critical, rule out first
- the six in the escalate box above → upper airway obstruction or anaphylaxis, tension pneumothorax, cardiac tamponade, high-risk PE, aortic dissection, acute heart failure with shock (cold, hypotensive, pulmonary edema)
common causes on the ward
- acute heart failure → orthopnea, PND, edema, raised JVP, crackles; IV fluids or blood given
- asthma → wheeze, prolonged expiration, accessory muscles
- COPD exacerbation → known COPD, more sputum or purulence
- pneumonia or aspiration → fever, cough, focal crackles, new infiltrate
- PE → pleuritic pain, tachycardia, immobility, DVT signs
- pneumothorax (non-tension) → reduced breath sounds one side, hyperresonance; recent central line
- ACS or arrhythmia → chest pain, palpitations, ECG change → chest pain, palpitations
- metabolic acidosis → deep breaths with a clear chest: DKA, sepsis, renal failure, toxins → venous blood gas
- anemia, fluid overload after transfusion → hemoglobin drop, transfusion reaction
- anxiety / hyperventilation → normal SpO₂, normal exam, a diagnosis of exclusion
focused check
- onset → minutes (PE, pneumothorax, anaphylaxis) vs hours to days (heart failure, pneumonia, exacerbation)
- symptoms → orthopnea, PND, leg swelling; chest pain, diaphoresis, palpitations; fever, cough, sputum; pleuritic pain, hemoptysis, calf pain
- history → asthma, COPD, ILD, heart failure, IHD, dialysis; recent surgery, immobility, OCP, prior VTE
- drug chart → diuretics given or missed, inhalers, anticoagulant held, IV fluids, blood products, opioids or sedatives; recent lines or procedures
- exam → work of breathing, ability to speak in sentences, air entry both sides, wheeze or crackles, JVP, heart sounds, edema, calves, mental status
send now
- gas → VBG screens pH and lactate; it does not reliably establish PaCO₂: ABG when hypercapnia is suspected, NIV is being decided, or the patient is deteriorating → venous blood gas
- NT-proBNP → when heart failure is in question: < 300 pg/mL makes acute heart failure unlikely; higher supports it but is not diagnostic; echo by the clinical picture
- troponin → if ACS, myocarditis or PE with RV strain is possible → troponin
- PE suspected → Wells first: low probability D-dimer; high probability or positive D-dimer CTPA
- CTPA delayed, high probability → start anticoagulation now if bleeding risk is low; unfractionated heparin if high
- CBC, renal profile, electrolytes; blood cultures if febrile
calculator Wells’ criteria (PE) · MDCalc ↗︎
imaging
- CXR → pneumothorax, effusion, consolidation, pulmonary edema, widened mediastinum
- bedside echo / POCUS → B-lines, effusion, tamponade, RV strain, pneumothorax; a normal scan does not stop the workup
- CTPA → PE by the pathway above; CTA aorta → dissection suspected; CT chest → CXR does not explain the picture, empyema, mass
treat
upper airway obstruction / anaphylaxis
- stridor → anesthesia and ENT now; sit up, high-flow oxygen, nothing by mouth
- anaphylaxis → IM epinephrine now, do not wait for IV access → allergic reaction
respiratory support: does this patient need a gas, NIV, intubation, ICU?
- target → 90–94%, never above 96%; 88–92% if hypercapnia risk; unsure → aim ~92%, send a gas
- conventional oxygen → nasal cannula, simple mask, non-rebreather
- HFNC for higher flow and FiO₂, mainly hypoxemic failure
- NIV → by work of breathing, instability, gas exchange and contraindications, not one RR or SpO₂ threshold: CPAP for pulmonary edema, bilevel for hypercapnic acidosis; ABG first, timed trial, gas at 1 h
- intubation when the step above fails or is not appropriate; call ICU before the patient is exhausted
- ICU now if → target not held despite escalating support; worsening gas or mental status on NIV; cannot protect the airway; exhausted; silent chest; peri-arrest
- criteria and settings → acute respiratory failure, HFNC & NIV, mechanical ventilation
acute heart failure / pulmonary edema
- sit up; stop IV fluids; oxygen to target; CPAP or NIV early for marked work of breathing or hypoxemia on oxygen, by the picture not a threshold
- furosemide → 40 mg IV if diuretic-naive, or double the daily oral dose given IV
- response → judge at 2 h (spot urine Na ≥ 70 mmol/L) or 6 h (urine output ≥ 100 mL/h); not met → escalate by BP, renal function, prior diuretic exposure and response (higher dose or a second class), with the treating team
- GTN SL or infusion if SBP > 110 mmHg → not after a PDE5 inhibitor, in RV infarct or severe aortic stenosis
- no routine opiates
- precipitant → ACS, arrhythmia, uncontrolled hypertension, missed dialysis, missed diuretic, IV fluids or transfusion
- hypotension or shock → ICU and cardiology now; inotropes or vasopressors before diuretics or vasodilators → cardiogenic shock
asthma exacerbation
- oxygen if SpO₂ < 92%, target 92–95%
- salbutamol 2.5–5 mg neb (or 4–10 puffs pMDI with spacer) every 20 min for the first hour, then by response; moderate or severe → add ipratropium 0.5 mg neb to each of the first three doses; continue it if severe or responding poorly
- steroid within 1 h → prednisolone 1 mg/kg PO OD, max 50 mg, for 5–7 days, no taper; cannot swallow, vomiting or on NIV → methylprednisolone 40 mg IV (or hydrocortisone 100 mg IV q6h, same effect)
- not responding after the first hour, or life-threatening → magnesium sulfate 2 g IV over 20 min, once
- reassess at 1 h → drowsy, silent chest, rising CO₂ or exhausted → ICU and anesthesia now
- no IV aminophylline, no sedatives; anaphylaxis features → epinephrine IM first
COPD exacerbation
- controlled oxygen, target 88–92%
- salbutamol 2.5–5 mg + ipratropium 0.5 mg neb, repeat salbutamol by response
- prednisolone 40 mg PO OD for 5 days, no taper; cannot swallow → methylprednisolone 40 mg IV
- antibiotic → purulent sputum with more dyspnea or volume, or needing NIV → empiric antibiotics
- gas → ABG after the first hour: pH ≤ 7.35 with PaCO₂ > 45 mmHg persisting → NIV, do not keep escalating oxygen; hypercapnia without acidosis, or doubt → repeat the gas at 1 h, decide with respiratory or ICU
pneumonia
- severity → CURB-65 plus the bedside picture
- antibiotics → CAP, or HAP if onset ≥ 48 h after admission; cultures first only if that costs no time → empiric antibiotics
- oxygen to target; IV fluids only if hypotensive or not drinking; sepsis criteria → fever
calculator CURB-65 · MDCalc ↗︎
pulmonary embolism
- anticoagulation → enoxaparin 1 mg/kg SC q12h; unfractionated heparin if renal impairment, instability or reperfusion is possible
- unstable (SBP < 90 mmHg) → ICU now; systemic thrombolysis unless contraindicated; dosing and reperfusion pathway → chest pain
aortic dissection
- CTA aorta, chest to pelvis; type A → cardiothoracic surgery and ICU now; type B → vascular surgery
- β-blocker first → labetalol or esmolol to HR < 60 and SBP 100–120 mmHg, or the lowest that keeps the patient perfused; vasodilator only after the rate is controlled; full dosing → chest pain
cardiac tamponade
- echo now; cardiology and ICU now; fluid bolus may buy time; avoid diuretics and vasodilators
- unstable → echo-guided pericardiocentesis; a stable effusion is drained in the cath lab → chest pain
pneumothorax / collapse
- tension → needle decompression now, do not wait for a CXR: 4th or 5th intercostal space anterior to the mid-axillary line, above the rib; 2nd intercostal space mid-clavicular is the alternative
- decompression is temporary → chest drain follows → oxygen desaturation
- non-tension → CXR now; size and symptoms decide observation vs chest drain, with respiratory or surgery
- lobar collapse → sit up, chest physiotherapy, suction; not clearing → respiratory for bronchoscopy
reassess
- when → 30–60 min after the first treatment, after any change of oxygen device, then hourly until stable
- what → RR, work of breathing, sentences or words; SpO₂ against the target and the flow needed to hold it; mental status, BP, HR; urine output if diuresed; gas at 1 h if hypercapnic or on NIV
- not improving → back to the differential: wrong diagnosis, a second process, a missed precipitant (fluids, transfusion, opioid); rising O₂ requirement, rising CO₂ or fatigue → ICU and the treating team now; do not watch for another hour
- hand over → working diagnosis, O₂ device, flow and target, treatments given, when the next gas and review are due, escalation trigger
see also, MOC+ Volume 2: Cardiopulmonary covers acute heart failure, PE, and asthma / COPD exacerbations in depth. browse the library.
evidence
| source | type |
|---|---|
| BMJ 2018 Rapid Recommendation, oxygen therapy for acutely ill medical patients | international guideline |
| GINA 2026 strategy report | international guideline |
| GOLD 2026 report | international guideline |
| 2026 ESC heart failure guideline (decongestion, Figure 15) | international guideline |
| ERS/ATS 2017 noninvasive ventilation guideline | international guideline |
| ATS/IDSA 2019 CAP and 2016 HAP/VAP guidelines | international guideline |
| 2026 AHA/ACC multi-society acute PE guideline | international guideline |
| 2022 ACC/AHA aortic disease guideline | international guideline |
| ATLS 10th ed. needle decompression | specialty-society guidance |
Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.
free the on-call checklist covers the whole shift on one printable page.
studying for the IM exam? the IM Rapid Review covers the breathless patient in the same format. see the sample chapter.
reviewed Jun 2026updated Oct 2026file complaint/dyspnea