Approach to Shortness of Breath: The BREATHE Mnemonic
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Example Case
A female patient presents with respiratory distress. Symptoms began approximately 2 days ago with productive cough. Over the past 24 hours she reports worsening shortness of breath.
She states that she has a history of COPD and attempted to use her home inhalers with minimal relief. Symptoms are worse with exertion. There is minimal improvement with rest. She denies associated chest pain, fevers, abdominal pain, nausea, or vomiting.
Shortness of Breath
Shortness of breath is a common chief complaint, yet the list of potential diagnoses is extensive. Furthermore, some causes of shortness of breath can be life threatening while others can be managed outpatient.
This diagnostic dilemma can create unnecessary stress and cause you to put a lot of pressure on yourself to not miss something bad.
Approaching shortness of breath in a systematic fashion can help reduce this stress and ensure you will appropriately manage the patient without missing emergent causes.
Similar to how the previous approach to chest pain blog used the 4-2-1 rule to remember the emergent causes of chest pain, and the previous approach to upper abdominal pain blog used the UPPER STOMACH mnemonic to remember the emergent causes to upper abdominal pain, this post will also provide a simple tactic to help remember all of the emergent causes of shortness of breath using the BREATHE mnemonic.
The BREATHE mnemonic below will make your life easier. It will help minimize the stress of wondering if you missed a life threatening diagnosis in a patient as it provides an easy method for remembering the main emergencies.
This post will also provide tools to organize your thought process when approaching a patient with shortness of breath along with useful history taking, diagnostic work up, and risk stratification strategies.
As with the other chief complaint blog topics, the purpose is to provide a guide on how to approach the undifferentiated patient. with shortness of breath.
It is not intended to advise you on how to definitively manage the patient as every case is different. However, approaching the undifferentiated patient in an organized manner will be helpful.
Initial Approach
The initial step to shortness of breath, as with any chief complaint, is performing a primary survey.
Does the patient look sick or not sick?
As IV access is obtained and the patient is hooked up to cardiac monitor and pulse oximetry, assess the patient’s airway, breathing, and circulation.
Airway: Are they speaking? Are they tolerating their secretions? Are you concerned for foreign body aspiration? Is there any airway obstruction? How is their mental status?
Breathing: Is it fast or slow? What are their breath sounds like? How is their work of breathing? Are they using accessory muscles? What is their pulse oximetry or ETCO2 on capnography?
Circulation: What is their blood pressure and heart rate? How is their capillary refill? Are their pulses present and equal throughout? Is the skin warm or dry?
If there are any concerns above, then action may need to be taken.
This could include providing oxygen support via nasal cannula or non-rebreather while optimizing their airway and positioning. They may require non-invasive positive pressure ventilation such as BIPAP. In some circumstances, the patient may need to be intubated urgently.
In addition to oxygenation and/or ventilatory support, they may require breathing treatments or other medications such as nitroglycerin in cases of acute pulmonary edema or epinephrine in cases of anaphylaxis.
If the blood pressure and/or circulation is of concern, then the patient may need IV fluids, pressors, or products depending on the situation. Consider the different types of shock that could be causing the patient’s decreased perfusion, and then work to address the underlying problem.
Reassess the patient’s vital signs after primary survey.
Lastly, any patient complaining of shortness of breath should have an immediate EKG on arrival.
Quick Chart Review
If time allows and the patient is stable, performing a quick chart review of the patient can also be helpful.
Review the patient’s age, sex, past medical history, medications, and vital signs, along with any previous echocardiograms, cardiac catheterizations, EKGs, chest imaging, or previous visits for shortness of breath.
Understanding the patient a little better based on a quick chart review can help to prepare you before entering the room, and may also drive you to ask more detailed questions about certain diagnoses.
Use caution however not to let a chart review bias you or lead to a premature diagnosis as you could miss something.
Shortness of Breath Chart Review Considerations
Vital Signs
Age
Sex
Past Medical History, Social History, Family History, Surgical History
Medications
Previous echocardiogram?
Previous cardiac catheterization?
Previous CT chest or chest x-rays?
Previous healthcare visits for similar complaint?
Previous EKG?
BREATHE Mnemonic
As mentioned above, there are many diagnoses that can lead to shortness of breath.
To complicate matters, some diagnoses are life threatening while others can be managed outpatient.
It will be challenging to think of absolutely every possible diagnosis as depicted below.
Therefore, the initial approach as with any undifferentiated patient should be to consider the most emergent causes first.
Once those have been ruled out or at least considered, then other less emergent causes can be addressed.
The mnemonic I came up with to help you remember the emergent intrathoracic causes of shortness of breath is BREATHE:
Bacteria (pneumonia, endocarditis), Reactive airway disease (asthma, COPD, anaphylaxis), Embolism (PE), ACS, Tension pneumothorax or Tamponade, Heart failure, and Electrical excitation (arrhythmias).
It is important to note that reactive airway disease is a nonspecific term that describes symptoms of wheezing and shortness of breath. However, for purposes of the mnemonic it is an easy way to remember all of obstructive and bronchospasm diseases that cause those symptoms.
***Reactive airway disease is a nonspecific term that describes symptoms of wheezing and shortness of breath. For purposes of the mnemonic it is an easy way to remember all of obstructive and bronchospasm diseases that cause those symptoms.
Shortness of Breath Differential
The BREATHE mnemonic is a great starting point to consider the emergent intrathoracic causes of shortness of breath.
You can combine this with the 4-2-1 rule for intrathoracic chest pain emergencies. Between the 4-2-1 rule and the BREATHE mnemonic, you will have considered most emergent intrathoracic etiologies to chest pain and/or shortness of breath.
If diseases in the BREATHE mnemonic have been ruled out or at least considered, then the next best approach is to organize other potential diagnoses by body or organ system as there are extrathoracic etiologies that can cause shortness of breath as well.
This is not meant to be a complete exhaustive list, but rather an example of how to organize it in your head.
Extrathoracic Etiologies to Shortness of Breath
ENT - Angioedema, epiglottitis, foreign body aspiration, Ludwig’s angina, retropharyngeal abscess, croup
Hematologic - Anemia
Abdominal - Ascites, pregnancy
Neurological - Myasthenia gravis, ALS, MS, Guillain-Barre, stroke
Musculoskeletal - Rib fracture
Toxidrome - Carbon monoxide poisoning, salicylate toxicity, inhalation exposure
Endocrine - DKA, metabolic acidosis, thyroid disease
Psychiatric - Panic attack, anxiety
History of Present Illness
It is important to obtain a thorough history from the patient. Having a clear understanding of the nature and pattern of their shortness of breath can guide you to prioritize and refine your differential as the list can be extensive as exemplified above.
You can ask the patient about symptom onset, timing, exacerbating or remitting factors, associated chest pain, wheezing, leg swelling, recent travel, recent surgeries, cough, fever, palpitations, abdominal pain, past medical history of respiratory diseases, etc.
Physical Exam
Physical examination in addition to a good history will help to refine your differential diagnosis.
Key aspects to your physical exam should include but are not limited to: oropharyngeal examination, auscultation of heart and lungs, assessment of jugular veins, assessment for accessory respiratory muscle usage, assessment of work of breathing, abdominal examination, assessment for peripheral edema, etc.
Diagnostic Investigation
Upon completion of your history and physical examination, you should have a much more refined and prioritized differential to the patient’s shortness of breath.
Work up will include everything in your differential and will be used to further support or potentially negate the etiologies in your list.
Work up considerations include:
Lab Considerations
CBC, chemistry, troponin, coagulation studies, BNP, d-dimer, blood gas, co-oximetry panel, pregnancy test, toxicology studies (salicylate, UDS, etc)
Imaging Considerations
Chest x-ray, EKG, and CT chest. You can perform a bedside ultrasound if you are ultrasound savvy to assess for causes such as pneumothorax, pericardial effusion/tamponade physiology, pneumonia, heart failure, and pleural effusion to name a few. You can also assess the IVC, different cardiac measurements, etc.
Risk Stratification and Assessment Tools
The point of this section is to educate you and/or refresh your memory on various tools out there that are used to risk stratify patients.
It is not meant to provide management or treatment advice. All rules and tools can be found online.
Pulmonary Embolism
Wells Criteria
Wells criteria can be used to risk stratify patients into low, moderate, and high risk for PE.
This could potentially help you decide if you want to first order a d-dimer on the patient and then a CT PE study subsequently if the d-dimer is elevated, or if you feel the patient is high enough risk that they may automatically benefit from a CT PE study without obtaining a d-dimer first.
There is a scoring system for each criterion listed below and the total points correlate with their risk stratification.
Clinical signs and symptoms of DVT (3 points)
PE #1 on differential or equally likely (3 points)
Heart rate > 100 (1.5 points)
Immobilization > 3 days or surgery < 4 weeks (1.5 points)
Previously diagnosed DVT or PE (1.5 points)
Hemoptysis (1 point)
Malignancy with treatment last 6 months (1 point)
PERC Rule
The PERC rule is primarily designed for patients who are low risk for PE.
If a patient does not have any of the PERC criteria present and they are low risk for PE, then no further diagnostic testing for PE can be considered.
If the patient does have 1 or more criteria present, then the PERC rule cannot be applied and consideration should be given to order a d-dimer if they are low risk for PE or straight to a CT PE study if they are high risk (although if they are high risk, you should not be using the PERC rule).
If any of the questions below are answered yes, then the PERC rule cannot be applied for ruling out PE.
Age >/= 50
Heart Rate > 100
Oxygen saturation < 95% on room air
Unilateral leg swelling
Hemoptysis
Recent surgery/trauma
Prior PE/DVT
Hormone use
Community Acquired Pneumonia
CURB-65
The CURB-65 score estimates 30-day mortality to determine inpatient versus outpatient care of community acquired pneumonia.
Each criterion below is 1 point if present. The patient’s total score correlates to a low, moderate, or high risk 30-day mortality group.
Confusion
BUN > 19
Respiratory Rate >/= 30
Systolic BP < 90 or Diastolic BP </= 60
Age >/= 65
Exam and Board Prep
Board, medical, and licensure exams commonly use buzzwords or phrases within the question stem. Knowing these will help you quickly associate what the examiner is testing you on.
Below are descriptions you may see on exams that correlate with that particular diagnosis.
This will not only help to summarize all the information, but may help you clinically or with any exam or board prep.
Conclusion
I hope that helps to organize your approach to shortness of breath.
Always start with a primary survey assessing the ABCs and the patient’s vital signs. Does the patient look sick or not sick? Obtain an EKG. Place an IV and hook them up to the cardiac monitor and pulse oximetry.
Remember the BREATHE mnemonic for the emergent intrathoracic causes of shortness of breath: Bacteria (pneumonia, endocarditis), Reactive airway disease (asthma, COPD, anaphylaxis), Embolism (PE), ACS, Tension pneumothorax or Tamponade, Heart failure, and Electrical excitation (arrhythmias). You can tie this into the 4-2-1 rule for chest pain emergencies.
Obtaining a thorough history and performing a strong physical examination can help to refine and prioritize your differential.
Work up should be based on ruling out emergent causes and investigating your most likely differential diagnoses. You can also use risk stratification tools to assist with your diagnostic work up and management.
Lastly, there are keywords and buzzwords for shortness of breath that are commonly used on exams and licensure boards. Knowing these will help you to quickly identify what the examiner is testing you on for that particular question.
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