Shortness of Breath

Questions

• 1.

  How long has the patient had SOB?

• 2.

  Was the onset slow or rapid?

  • A rapid onset suggests pneumothorax or pulmonary embolus.

• 3.

  Is the patient cyanotic?

• 4.

  Is the patient already on oxygen (O ₂ )? What is the patient’s arterial hemoglobin saturation (Sa O ₂ )?

• 5.

  Does the patient have a history of chronic obstructive pulmonary disease (COPD)?

  • If the patient retains carbon dioxide (CO ₂ ), the amount of O ₂ that may be delivered is affected.

• 6.

  Has the patient undergone a surgical procedure, and if so, how long ago?

  • Be especially mindful after placement of central lines.

• 7.

  Are there any other symptoms such as chest pain, cough, or fever?

• 8.

  Are there any changes in the patient’s vital signs?

Orders

• 1.

  Measure SaO ₂ by pulse oximetry if not already done.

  • As an alternative, have an arterial blood gas (ABG) kit at the bedside. This will give a rapid indication of the arterial partial pressure of oxygen (PaO ₂ ).

• 2.

  Deliver O ₂ as necessary.

  • If the patient does not retain CO ₂ , O ₂ may be safely delivered at a rate that keeps the O ₂ saturation at greater than or equal to 93%. See Table 28.1 for various regimens of O ₂ delivery.

    Table 28.1

    Oxygen Delivery Techniques

    System	Recommended Flow	Maximum FiO 2	Humidification	Control of FiO 2
    Room air	N/A	0.28	Poor	N/A
    Nasal cannula	1–6 L/min	0.44	Poor	Poor
    Open face mask	8–10 L/min	0.44	Good	Good
    Venturi mask	10 L/min	0.45	Poor	Great
    Tight face mask	8–10 L/min	0.60	Poor	Good
    Non-rebreather mask	10 L/min	1	Poor	Good
    Endotracheal tube	N/A	1	Great	Great

    FiO ₂ , fraction of oxygen in inspired air.

• 3.

  If the patient has a history of reactive airway disease (RAD; COPD or asthma), order bronchodilator treatment if it has been more than 2 hours since the last treatment ( Table 28.2 ).

  Table 28.2

  Bronchodilator Therapies to Control Reactive Airway Disease

  Generic	Trade	Dosage	Interval
  β-2 Agonists
  Albuterol	Proventil, Ventolin	2.5–5 mg in 3 mL NS	q4–6h
  		2 puffs of MDI	q4–6h
  		2–4 mg PO	q4–8h
  Fenoterol	Berotec	0.5–1.0 mg in 3 mL NS	q4–6h
  Isoetharine	Bronkosol	0.3 mg in 2.7 mL NS	q4–6h
  		2 puffs of MDI	q4–6h
  Metaproterenol	Alupent, Metaprel	0.3 mg in 2.7 mL NS	q4–6h
  		2 puffs of MDI	q4–6h
  		10 mg PO	q6h
  Terbutaline	Brethaire, Bricanyl	0.25–0.5 mg in 2.6 mL NS	q6–8h
  		2 puffs of MDI	q6–8h
  		2.5–5 mg PO	q6–8h
  Anticholinergics
  Ipratropium	Atrovent	0.5 mg in 3 mL NS	q6–8h
  Bromide		2 puffs of MDI	q6h
  Atropine		0.5–1 mg in 3 mL NS	q8h
  Generic	Trade	Dosage	Interval
  Intravenous Medications
  Epinephrine (1:1000)		0.25–0.5 mg IM	Every 8–12 h
  Aminophylline (not first-line)	5 mg/kg IV over	20–30 min
  Loading		0.6–0.9 mg/kg/hrIV (maintain levels at 10–20 mcg/mL)
  Maintenance		6 mg/kg q12h of the long-acting preparation

  Medication	IV Dose	PO Dose	Dose Equivalency a
  Steroids
  Hydrocortisone	250 mg bolus, then 3–5 mg/kg divided q6h	—	1
  Methylprednisolone	1–1.5 mg/kg	—	5
  Prednisone	—	1–1.5 mg/kg	4
  Dexamethasone	0.1–0.2 mg/kg	5–10 mg	25–30

  IM, intramuscularly; IV, intravenously; MDI, metered dose inhaler; NS, normal saline; PO, orally.

  a Glucocorticoid potency compared with hydrocortisone milligram per milligram.

Degree of Urgency

The patient must be evaluated immediately.

Surgical Chart Biopsy

• Vital sign trends are important. What has the patient’s HR trend been?

• Has the patient’s blood pressure (BP) decreased?

• Has the patient required increasing amounts of O ₂ ?

• What is the patient’s urine output? What is the patient’s fluid balance today and over the duration of the hospitalization?

Cardiovascular Causes

• 1.

  Congestive heart failure (CHF)

• 2.

  Pulmonary embolism (PE)

• 3.

  Cardiac tamponade

Pulmonary Causes

• 1.

  Atelectasis (usually 24−48 hours after a surgical procedure)

• 2.

  RAD (e.g., COPD, asthma, or gastroesophageal [GE] reflux)

• 3.

  Upper airway obstruction

• 4.

  Pneumothorax

• 5.

  Pleural effusion

• 6.

  Pneumonia

• 7.

  Aspiration of gastric contents

Miscellaneous Causes

• 1.

  Anxiety

• 2.

  Marked abdominal distention

Quick Look Test

Hypoxia is evident by agitation and cyanosis. Patients with significant hypoxia will appear anxious and ill. CO ₂ retention is evident by lethargy or obtundation.

Airway and Vital Signs

Confirm the patency of the upper airway. Remove any oral obstruction such as dentures or foreign bodies. Tachypnea (respiration rate [RR] >20 breaths/minute) will be present if hypoxia, anxiety, pain, or acidosis is present. Slow RRs (<12 breaths/minute) indicate a depression of the central nervous system (CNS) with medications (such as opiates) or primary cerebral lesion. If there is a cardiac cause, tachycardia or arrhythmia may also be present. Fever denotes an infectious cause but also may be present with atelectasis or PE. A drop in BP may indicate PE, tension pneumothorax, CHF, or sepsis.