Acute dyspnea
(Redirected from Breathlessness)
This page is for adult patients. For pediatric patients, see: acute dyspnea (peds).
Background
Clinical Features
Emergent Pattern Recognition
| Diagnosis | Lungs | CXR | ECG | Treatment | Contraindicated |
| Pulmonary Edema | Bilateral rales | Interstitial fluid | Normal/abnormal | R/O AMI, lasix, nitrates, ACEi, BiPAP | IVF; ?albuterol; ?Beta-blockers |
| Bronchoconstriction | Wheezes | Clear/hyperinflated | Normal/pulmonary strain | Albuterol, atrovent, steroids, consider anaphylaxis (epi) | Beta-blockers; ?aspirin |
| Pneumonia | Focal ronchi/decreased breath sounds | Infiltrate/effusion | Normal | IVF, antibiotics | Rate control; diuresis |
| Pulmonary embolism | Clear | Clear (most) or Westrmark/Hampton hump | Normal/S1Q3T3 | Anticoagulate/thrombolytics | Rate control |
| Pneumothorax/Hemothorax | Unequal | Pneumo/hemo | Normal | Needle thoracentesis/chest tube | Rate control |
| Dysrythmia | Clear/pulmonary edema | Clear/pulmonary edema | Abnormal | Type dependent | Albuterol; ?IVF |
| ACS | Clear/pulmonary edema | Clear/pulmonary edema | Normal/abnormal | Aspirin; nitrates, anticoagulation, ?beta-blockers, +/- thrombolytics | Albuterol; ?IVF |
Differential Diagnosis
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Evaluation
Bedside Lung Ultrasound in Emergency (BLUE) Protocol[1]
- Landmark study by a French intensivist that described various profiles of specific pulmonary disease found on US[2]
- Ultrasound approaches include anterior zones and PLAPS (posterior or lateral alveolar and/or pleural syndrome) point, which is located at the posterior axillary line similar to FAST view
- Predominant A lines anteriorly + lung sliding = Asthma/COPD
- Multiple predominant B lines anteriorly + lung sliding = Pulmonary Edema
- Predominant A lines anteriorly + lung sliding + positive DVT = PE
- Absent anterior lung sliding + anterior A lines + positive lung point = Pneumothorax (PTX)
- PLAPS findings +/- A or B lines +/- abolished lung sliding = Pneumonia
- PLAPS describes changes at the PLAPS point, usually related to consolidations and pleural effusions[3]
- Consolidations may include lung hepatization, shred sign, air bronchograms
- Note that mirroring (normal) may appear similar to hepatization, but mirroring only shows in specific spots due to specific echogenic windows
- Pleural effusions are visualized as anechoic/hypoechoic areas with possible spine sign or floating lung sign (sinusoid sign on M-mode)
- A suggested BLUE protocol guides diagnosis of dyspnea; this should be modified as needed based on clinical presentation
- Check lung sliding in anterior lung fields ---> check for A and B lines ---> check for PLAPS findings
Management
- Oxygen
- Treat underlying cause
Disposition
See Also
References
- ↑ http://ccm.anest.ufl.edu/files/2012/08/BLUELung.pdf Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure - The BLUE Protocol
- ↑ Lichtenstein DA, Mezière GA. Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol. Chest. 2008 Jul;134(1):117-25. doi: 10.1378/chest.07-2800. Epub 2008 Apr 10. Erratum in: Chest. 2013 Aug;144(2):721. PMID: 18403664; PMCID: PMC3734893.
- ↑ Lichtenstein DA. Lung ultrasound in the critically ill. Ann Intensive Care. 2014 Jan 9;4(1):1. doi: 10.1186/2110-5820-4-1. PMID: 24401163; PMCID: PMC3895677.