Basics
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 " Barre 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
- 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
- Amniotic fluid embolism during or after delivery
- Septic embolism from septic abortion or postpartum uterine infection
Diagnosis
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
- 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
- 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.
Treatment
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
- Pyridostigminebromide or neostigmine for myasthenia gravis
- Metabolic/toxic:
- Psychogenic:
- 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.
- Supportive oxygen therapy and heparin for PE or amniotic fluid embolism
- IV antibiotics for septic embolism
Medication
Refer to specific etiologies
Follow-Up
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
Pearls and Pitfalls
- Consider immune-compromised state.
- Consider "novel " flu strains (H1N1).
- Start antibiotic treatment within 6 hr of ED arrival (JCAHO Quality Measure).
Additional Reading
- 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.
Codes
ICD9
- 786.00 Respiratory abnormality, unspecified
- 786.05 Shortness of breath
- 786.09 Other respiratory abnormalities
- 464.4 Croup
- 464.30 Acute epiglottitis without mention of obstruction
- 490 Bronchitis, not specified as acute or chronic
- 519.8 Other diseases of respiratory system, not elsewhere classified
ICD10
- R06.00 Dyspnea, unspecified
- R06.02 Shortness of breath
- R06.09 Other forms of dyspnea
- J05.0 Acute obstructive laryngitis [croup]
- J05.10 Acute epiglottitis without obstruction
- J40 Bronchitis, not specified as acute or chronic
- J98.8 Other specified respiratory disorders
SNOMED
- 271825005 Respiratory distress (finding)
- 267036007 Dyspnea (finding)
- 230145002 difficulty breathing (finding)
- 71186008 Croup (disorder)
- 68372009 Upper respiratory tract obstruction (disorder)
- 80384002 Epiglottitis (disorder)
- 85915003 Laryngotracheobronchitis