This document discusses the high risk condition of dyspnea, or difficulty breathing. Dyspnea accounts for 2-3% of emergency department visits and requires prompt evaluation to detect life-threatening causes. The evaluation of dyspnea involves taking a thorough history including symptoms and onset, performing a physical exam checking vital signs, lungs, heart and skin, and ordering diagnostic tests like chest x-rays, ECGs, blood tests and echocardiograms. Patients with rapid respiratory distress may require airway management or positioning to improve breathing. Pulmonary embolism is one potential cause that is often difficult to diagnose due to its variable presentation but requires recognition to prevent fatal outcomes.

1. HIGH RISK CONDITION OF DYSPNEA
Adib Mursyidi Iskandar Mirza
A&E Department

2. DEFINITION/ETIOLOGY/EPIDEMIOLOGY
 Perception of inability to breathe comfortably
 In ED, 2-3% of all visit complain of
respiratory distress  may have conjunction
with other symptoms e.g. diaphoresis, chest
pain, palpitation, cough, fever
 Goal in ED: detection of life threatening
causes of dyspnea

4. EVALUATION
 History:
 Timing: acuity and duration (onset, acute,
chronic, recurring?)
 Patient description (SOB, breathlessness,
trouble breathing, suffocating, chest tightness,
etc.)
 Severity (using Borg scale)
 Associated symptoms (any special concern e.g.
chest pain, fever, cough)
 Past medical history/Medication/Social history

6. PHYSICAL EXAMINATION
 Vital sign (hypotensive, RR, HR)
 Head and neck (oral cavity, jugular vein,
Kussmaul sign, stridor)
 Pulmonary exam (recession, accessory
muscle, subcutaneous emphysema)
 Cardiac exam (murmurs)
 Extremity exam (cyanosis, edema, clubbing)
 Skin (diaphoresis)

7. DIAGNOSTIC TESTING
 Pulse oximetry
 Chest radiography
 ECG (ischemia, atrial fibrillation)
 Lab study
 ABG
 Hb/Hct, cardiac test (trop, CK)
 Echo (effusion, valvular dysfunction, wall motion)

8. TREATMENT/DISPOSITION
 Patient with rapid respiratory distress need
rapid evaluation of airway
 Altered mental status, inability to speak,
inadequate ventilation may required airway
management
 Sit the patient in upright position  maximize
accessory muscle use and decrease
pulmonary congestion
 Do not discharge pt with unexplained
dyspnea

14. PULMONARY EMBOLISM
 Most cases of fatal PE  unrecognized
 Isolated dyspnea is one of most common
symptoms (1/3 report dyspnea without chest
pain)
 2/3 of patient with PE had painful dyspnea
(with/out + hemoptysis)

15.  Diagnosis  difficult in view of variable
presentation
 Pt may had normal pO2 by pulse oximetry of
ABG
 CXR: common infiltrate and pleural effusion

16. THANK YOU
 References
 Dyspnea: Fear, Loathing and Physiology,
Emergency Medicine Practice, Jeffery A. Kline,
MD
 Shirley Ooi 2nd edition: Acute breathlessness