Dyspnea: Subjective breathing discomfort

  • Common ED complaint (~7.5% of all presentations)
  • Multiple causes including, but not limited to CNS lesions, trauma, abdominal pathology as well as more common cardiac and pulmonary causes.

Approach: The initial assessment is driven by a need to distinguish the life threatening (i.e. tension pneumothorax) from benign (i.e. panic attack) and to distinguish pathologies that vary in frequency from common to obscure. While dyspnea and tachypnea may commonly result from hypoxemia, premature closure and anchoring bias are dangerous and can lead to misapplication of ineffective therapies and delays in treatment of the underlying diagnosis.

Basic Management

  • Review vital signs
  • Assess airway, breathing and circulation. If compromise of A, B or C, consider immediate intervention before moving on
  • Place large bore IV X 2, Consider supplemental O2 if hypoxic and place on a cardiac monitor

Direct assessment of breathing

  • Recorded respiratory rates in triage vital signs often inaccurate
  • Pay close attention to breathing rate + pattern
    • Tachypnea: Rapid breathing
    • Bradypnea: Slow breathing
    • Hypopnea: Decreased depth of breathing
    • Hyperpnea: Increased depth of breathing.
    • Orthopnea: Pulmonary congestion upon reclining
    • Kussmaul breathing: Slow, deep respirations typically associated with severe metabolic acidosis (e.g, DKA).
    • Cheyne–Stokes Respiration: Alternating periods of crescendo-decrescendo hyperventilation and apnea – may occur with cerebral hypoperfusion from any cause.

Physical Exam

    • Global Assessment
      • Assess overall work of breathing
      • Speech: full sentences, 3-4 words
      • Head/Neck positioning
    • Assess upper airway + neck
      • Listen for stridor (indicating upper airway obstruction)
      • See if patient can tolerate their own secretions
      • Examine for swelling (i.e. angioedema, anaphylaxis, Ludwig’s angina)
      • Look for signs of trauma
      • Look for JVD
    • Assess chest wall
      • Look for signs of trauma
      • Look for retractions and accessory muscle use
      • Check for asymmetry in movement
    • Auscultate
      • Lungs: Breath sounds for consolidations, dullness, absence of breath sounds, crackles, and wheezing
      • Heart: New murmurs, laterally displaced PMI, muffled heart sounds
    • Examine the Lower Extremities
    • Neurologic exam: Global weakness, focal neurologic deficit

Focused Point of Care Ultrasound (POCUS)

    • POCUS can rapidly distinguish between etiologies and guide critical interventions (Laursen 2014)
    • Cardiac Assessment
      • Global LV function
      • Global RV function
      • Presence of pericardial effusion or tamponade
    • Pulmonary Assessment
      • Presence of B-lines
        • Bilateral: Pulmonary edema
        • Unilateral: Pneumonia
      • Absence of lung sliding
      • Presence of consolidation
      • Presence of pleural effusion
    • Extremities for identification of DVT

Consider the Wide Differential

  • Dyspnea + abnormal breath sounds
    • Unilateral absent breath sounds: Pneumothorax (consider tension pneumothorax with absent breath sounds and tracheal shift and/or hypotension)
    • Bilateral absent breath sounds (“quiet chest”): Severe asthma/COPD
    • Focal decreased breath sounds: Pleural effusion, Pneumonia
    • Wheezing (particularly with a prolonged expiratory phase): COPD, asthma, organophosphate poisoning
    • Crackles: Heart failure, pulmonary edema
  • Dyspnea + clear breath sounds
    • Pulmonary Embolism
    • Acute Coronary Syndrome (myocardial infarction or ischemia)
    • Pulmonary hypertension
    • Pericardial tamponade
    • Anemia
    • Metabolic acidosis


Laursen CB et al. Point-of-care ultrasonography in patients admitted with respiratory symptoms: a single-blind randomized controlled trial. Lancet Respir Med 2014; 2(8): 638-46. PMID: 24998674

Barbera AR, Jones MP. Dyspnea in the Elderly. Emerg Med Clin North Am. 2016;34:543-58. PMID: 27475014

Bianchi W et al. Revitalizing a vital sign: improving detection of tachypnea at primary triage. Ann Emerg Med. 2013;61:37-43.  PMID: 22738682

DeVos E, Jacobson L. Approach to Adult Patients with Acute Dyspnea. Emerg Med Clin North Am. 2016;34:129-49. PMID: 26614245

Lovett PB et al. The vexatious vital: neither clinical measurements by nurses nor an electronic monitor provides accurate measurements of respiratory rate in triage. Ann Emerg Med. 2005;45:68-76. PMID: 15635313

Rice M et al. Approach to metabolic acidosis in the emergency department. Emerg Med Clin North Am. 2014;32:403-20. PMID: 24766940

Wills CP et al. Pitfalls in the evaluation of shortness of breath. Emerg Med Clin North Am. 2010;28:163-81. PMID: 19945605

Viniol A et al. Studies of the symptom dyspnoea: a systematic review. BMC Fam Pract. 2015;16:152. PMID: 4619993