The patient has been admitted for acute severe dyspnea. Initially tachypnea 30/min with respiration discomfort, anxiety, BP 210/110. Quite good saturation with an oxygen mask by normal breath mechanics. Fine inspiratory crackles bilaterally. No abdominal pathology found, lower limbs without oedema, well-perfused periphery, pink mucous membranes. History of hypertension.
The patient has been admitted to the emergency department. Further patient´s history is not possible because of severe dyspnea and anxiety. The patient denies pain.
What will be your next steps?
- Administer diuretics?
- Administer vasodilator?
- Start non-invasive ventilation?
- Administer opiate to reduce dyspnea?
- Wait for results of paraclinical examinations (BNP, troponin, complete blood count, CRP, D-dimers, chest X-ray, …)?
Management of severe dyspnea starts with the exclusion of life-threatening causes – airway obstruction, pneumothorax, extensive infiltration of lung tissue, alveolar flooding (any cause of lung oedema, haemorrhage), a severe pleural effusion of any aetiology, paresis of breathing muscles or thoracic wall pathology, severe metabolic acidosis, severe anaemia.
Based on the clinical finding, the differential diagnosis may be restricted to pneumothorax / pleural effusion (auscultation may not be reliable), alveolar flooding, infiltration of lung tissue and respiratory compensation of severe metabolic acidosis.
In my opinion, for the next step the option 4) is the best one at this moment, eventually followed by non-invasive ventilation. We will help the patient and gain more time for a diagnostic procedure. Relieving anxiety itself will probably result in a drop in blood pressure.
Paraclinical examinations require some time; thus, we can use an ultrasound machine and start with BLUE protocol (a protocol used in the differential diagnosis of severe dyspnea with acute onset in not hospitalised patients):