Initial Management of Shortness of Breath

Initial Assessment

The American Thoracic Society recommends performing an 'ABC' assessment followed by obtaining a quick history from the patient and/or family 2
Record vital signs including pulse rate, respiratory rate, blood pressure, and oxygen saturation via pulse oximetry, as recommended by the British Thoracic Society 2
Note signs suggesting significant respiratory distress: audible wheeze, tachypnea, use of accessory muscles, peripheral edema, cyanosis, and/or confusion, as indicated by the European Respiratory Society 3
Assess for history of COPD, asthma, or other chronic respiratory conditions that may affect management, according to the Global Initiative for Chronic Obstructive Lung Disease 1

Measure arterial blood gas tensions, noting the inspired oxygen concentration (FiO₂), as recommended by the American College of Chest Physicians 1
Obtain a chest radiograph to rule out pneumonia or other complications, as suggested by the British Thoracic Society 1, 3
Perform an ECG to assess for cardiac causes of shortness of breath, according to the American Heart Association 1
Complete blood count and basic metabolic panel should be obtained within the first 24 hours, as recommended by the Society of Critical Care Medicine 1

For patients with suspected COPD, the British Thoracic Society recommends initially limiting oxygen to 28% via Venturi mask or 2 L/min via nasal cannulae until arterial blood gas results are available 1, 2, 4
Target oxygen saturation of 88-92% to prevent hypercapnic respiratory failure, as suggested by the American Thoracic Society 2, 4
Check blood gases within 60 minutes of starting oxygen and after any change in inspired oxygen concentration, according to the European Respiratory Society 1

Administer nebulized bronchodilators immediately for patients with suspected obstructive airway disease, as recommended by the Global Initiative for Chronic Obstructive Lung Disease 1, 3
For moderate exacerbations, use a β-agonist (salbutamol 2.5-5 mg or terbutaline 5-10 mg) or an anticholinergic drug (ipratropium bromide 0.25-0.5 mg), according to the American College of Chest Physicians 1
For severe exacerbations or poor response to single agent, administer both β-agonist and anticholinergic medications, as suggested by the British Thoracic Society 1

For COPD exacerbation, consider systemic corticosteroids (prednisolone 30 mg/day orally or 100 mg hydrocortisone IV if oral route not possible) for 7-14 days, as recommended by the Global Initiative for Chronic Obstructive Lung Disease 1, 4
Initiate antibiotics if signs of infection are present (purulent sputum, fever), according to the American Thoracic Society 1, 4

Repeat arterial blood gas measurements if the clinical situation deteriorates, as recommended by the American College of Chest Physicians 1
Monitor oxygen saturation continuously with pulse oximetry, according to the Society of Critical Care Medicine 1, 4
Record initial FEV₁ and/or peak flow and start a serial peak flow chart when possible, as suggested by the European Respiratory Society 1