Originally published in the Ottawa Citizen, August 10, 2004

Shortness of breath (dyspnea) strikes deep at a person’s self-preservation instincts. The fear of suffocation commonly leads to a feeling of panic. The ability to diagnose and treat the condition depends upon past medical history, the ability to gather a good medical history of the acute condition and prompt evaluation of the patient’s physical findings.

We will run through a template for your use to help you gauge you first course of action. Acute shortness of breath is best assessed in an emergency department setting because it is equipped to manage, treat, and diagnose the problem.

It is a parent’s nightmare to see there newborn child or infant struggle to breathe. The ensuing panic understandably clouds the parent’s ability to assess the situation. Often, patients or family members will call their doctor’s office or help-line for advice.

An infant that is in respiratory distress will have these signs:

1)      The skin between their ribs tugs inward (indrawing)

2)      The abdomen pops outward while their ribcage pulls inward with each effort to breathe inward, then the reverse happens (paradoxical breathing).

3)      There is indrawing at the semi-circular notch at the top of the breastbone (sternum).

4)      The nostrils flare in order to maximize air intake.

5)      The head bobs forward with each inspiration

6)      Grunting noises

There are six criteria to consider in children when they are short of breath:

• Are they less than three months of age?
• Did the dyspnea start suddenly?
• Does the child have a sore throat?
• Do they have a croupy cough (sounds like a barking seal)?
• Are they lethargic?
• Do they have a temperature of 38.8 ºC of 102 ºF?

Answering “yes” to one or more of these questions requires prompt emergency department evaluation. If all the answers are “no”, the child needs a same-day office visit to his or her doctor.

The most common causes of shortness of breath in children are lung infections like pneumonia, croup and infection and swelling of the smaller airways (bronchiolitis).

Adults have a different set of criteria to assess whether urgent care is required:

• Do they have severe dyspnea?
• Are they experiencing dyspnea at rest?
• Is this the first time they have felt short of breath at rest?
• Do they have a sudden onset of chest pain?

An affirmative answer to any one of these criteria requires an emergency department assessment. If the patient has a history of congestive heart failure or chronic obstructive pulmonary disease but answers “no” to the above questions they must inform his or her doctor and pay them a same-day visit to adjust the treatment regimen.

The causes of dyspnea in adults are legion: congestive heart failure (CHF) asthma attacks, chronic obstructive pulmonary disease (COPD), heart attack, foreign-body obstruction of the airways and panic attacks among the many other causes.

Some of the other causes of dyspnea are revealed by a thorough patient history and physical exam. For example, a severe sore throat that is associated with shortness of breath may be due to a swollen epiglottis. The epiglottis is a flap of tissue that acts as a protective shield by covering the entrance into the lungs when you swallow food. If it swells too much it can lead to an airway obstruction.

Each symptom or sign may relate to a specific cause of dyspnea. Asthma and pneumonia are linked with cough. A painful chest wall can direct the physician to think about a collapsed lung (pneumothorax), pneumonia, a blood clot in the lung (pulmonary embolism) or inflammation of the outer skin covering the heart (pericarditis).

Someone who suddenly wakes up at night and bolts upright to catch their breath, requires pillows to prop up his or her head because they cannot breathe if they lie down or has markedly swollen feet may be suffering from a sudden exacerbation of congestive heart failure.

Tobacco users are at risk of developing chronic obstructive lung disease, congestive heart failure and pulmonary embolism.

Indeed there is an interrelationship between all these signs and symptoms. It is imperative to assess shortness of breath symptoms quickly because some of the causes cause greater harm in a shorter time frame than others.