Management of Shortness of Breath with Differential Diagnosis

Initial Assessment and Diagnostic Approach

The American College of Emergency Physicians recommends obtaining BNP or NT-proBNP levels in all patients presenting with acute dyspnea to distinguish cardiac from non-cardiac causes, with a diagnostic utility supported by studies 1, 2.
Patients with symptoms such as orthopnea and paroxysmal nocturnal dyspnea are likely to have cardiac causes, particularly heart failure, as suggested by guidelines from the European Society of Cardiology 3, 4.
The onset, duration, and timing of dyspnea can indicate specific conditions, such as pulmonary embolism, pneumothorax, or acute heart failure for acute onset, and COPD, interstitial lung disease, or chronic heart failure for chronic dyspnea, based on recommendations from the American Thoracic Society 4.
Associated symptoms like fever, chest pain, and cough with sputum can suggest pneumonia, cardiac ischemia, or COPD, respectively, as outlined by the Infectious Diseases Society of America 5, 4.
Risk factors including hypertension, diabetes, and atrial fibrillation increase the likelihood of heart failure, while smoking history suggests COPD or interstitial lung disease, according to the American Heart Association 3, 4.

The European Society of Cardiology recommends a BNP cutoff of >100 pg/mL or NT-proBNP >300 pg/mL to proceed with echocardiography for cardiac evaluation, with sensitivity and specificity supported by studies 1, 2, 3, 4.
Chest X-ray is the first-line imaging modality for all patients with dyspnea, useful for identifying cardiomegaly, pulmonary vascular congestion, infiltrates, pleural effusion, and hyperinflation, as suggested by the American College of Radiology 4.
Echocardiography is crucial for assessing cardiac function, evaluating left ventricular ejection fraction, diastolic function, valvular abnormalities, and right ventricular function, recommended by the American Society of Echocardiography 3, 4, 6.

For heart failure, increasing diuretic therapy and optimizing afterload reduction with ACE inhibitors or ARBs are recommended, along with admission for severe symptoms, as outlined by the American College of Cardiology 4, 1.
In COPD/asthma exacerbation, bronchodilators, systemic corticosteroids, supplemental oxygen, and antibiotics for bacterial infection are suggested, based on guidelines from the Global Initiative for Chronic Obstructive Lung Disease 4.
For pneumonia, broad-spectrum antibiotics, supplemental oxygen, and consideration of COVID-19 testing are recommended, as suggested by the Infectious Diseases Society of America 4, 5.

Referral to cardiology is indicated for cardiac symptoms or risk factors with elevated BNP, suspected HFpEF, elevated tricuspid regurgitation velocity, or severe valvular disease, based on recommendations from the American College of Cardiology 4, 6.
Referral to pulmonology is suggested for chronic dyspnea of unclear etiology, suspected interstitial lung disease, post-COVID complications, or symptoms not responding to standard COPD/asthma therapy, as outlined by the American Thoracic Society 4.