Initial Approach and Emergency Management

The initial approach of the emergency physician to a patient with dyspnoea must be a rapid evaluation of the vital signs following the standard ‘ABC’ approach to establish whether there is incipient risk to the airway, respiratory failure or cardiovascular compromise that would demand immediate resuscitation (see Figure 1). Click the image to see a large version.

The physician must perform a primary survey in any patient presenting with significant dyspnoea, immediately assessing the heart rate, respiratory rate, blood pressure, and oxygen saturation, auscultating the chest and evaluating the use of accessory muscles, inability of the patient to speak due to breathlessness, lethargy, agitation, and exhaustion; these features imply impending respiratory failure and the potential need for airway control and urgent ventilatory support (i.e. resuscitation).

Patients who do not require immediate resuscitation will have their management guided by a more thorough clinical assessment commencing with a focussed history and examination. As stated earlier, the primary question to be addressed during initial clinical assessment in the ED is whether the dyspnoea is primarily of a respiratory, cardiac, or other cause. By using a systematic and structured approach (see Figure 1) to the clinical assessment of a patient presenting with breathlessness a confident diagnosis will be achieved allowing effective management of the underlying condition.

Learning Bite

Any patient with significant dyspnoea will require a rapid assessment of their vital signs followed by appropriate resuscitation (airway support, supplemental oxygen, ventilatory support, etc.).