Last updated: September 15, 2020
Dyspnea, or shortness of breath, is a commonly reported symptom in acute care and outpatient settings. Causes of dyspnea include pulmonary (e.g., pneumonia, asthma exacerbation), cardiac (e.g., acute coronary syndrome, congestive heart failure), toxic-metabolic (e.g., metabolic acidosis, medications), and upper airway (e.g., epiglottitis, foreign body) pathologies. On initial presentation, it is important to immediately evaluate the patient for any urgent or life-threatening causes of dyspnea with patient history, physical examination, and diagnostic testing. Once immediately life-threatening causes are ruled out, a more detailed patient history should be obtained and further testing should be done to narrow the differential diagnoses.
Approach to management
- ABCDE survey
- Establish IV access, cardiac and pulse oximetry monitoring.
Start supplemental oxygen as needed.
Assess the need for ventilation support and airway management.
- Stabilize cardiovascular function (e.g., IV fluid resuscitation).
Perform focused history, examination, and diagnostics to rule out life-threatening reversible causes (see “Diagnostics” below).
- Once life-threatening causes have been ruled out:
- Treat the underlying cause.
Red flags for dyspnea
Immediately life-threatening causes
The diagnostic workup should be guided by the pretest probability of the diagnoses under consideration. The following list includes some commonly used diagnostic tools that can help to diagnose or rule out possible etiologies in patients with acute dyspnea.
Initial workup 
Further diagnostics to consider
Upper airway causes
Toxic-metabolic and other causes
The differential diagnoses listed here are not exhaustive.
Morgan WC, Hodge HL. Diagnostic evaluation of dyspnea.. Am Fam Physician. 1998; 57
Zoorob RJ, Campbell JS. Acute dyspnea in the office.. Am Fam Physician. 2003; 68
Updated: April 1, 2018.
Accessed: November 4, 2019.
Berliner D, Schneider N, Welte T, Bauersachs J. The differential diagnosis of dyspnea. Dtsch Arztebl Int. 2016; 113
doi: 10.3238/arztebl.2016.0834 . | Open in Read by QxMD
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases. 2007; 44
doi: 10.1086/511159 . | Open in Read by QxMD
Stoller JK. Acute Exacerbations of Chronic Obstructive Pulmonary Disease. N Engl J Med. 2002; 346
doi: 10.1056/nejmcp012477 . | Open in Read by QxMD
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report).
Accessed: June 27, 2019.
Camargo CA, Rachelefsky G, Schatz M. Managing Asthma Exacerbations in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbations. Proc Am Thorac Soc. 2009; 6
doi: 10.1513/pats.p09st2 . | Open in Read by QxMD
Leech C, Porter K, Steyn R, et al. The pre-hospital management of life-threatening chest injuries: A consensus statement from the Faculty of Pre-Hospital Care, Royal College of Surgeons of Edinburgh. Trauma. 2016; 19
doi: 10.1177/1460408616664553 . | Open in Read by QxMD
Leigh-Smith S, Harris T. Tension pneumothorax--time for a re-think?. Emergency Medicine Journal. 2004; 22
doi: 10.1136/emj.2003.010421 . | Open in Read by QxMD
Baumann MH, Strange C, Heffner JE, et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement.. Chest. 2001; 119
doi: 10.1378/chest.119.2.590 . | Open in Read by QxMD
MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65
(Suppl 2): p.ii18-ii31.
doi: 10.1136/thx.2010.136986 . | Open in Read by QxMD
Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease. Chest. 2016; 149
doi: 10.1016/j.chest.2015.11.026 . | Open in Read by QxMD
Al-Salem A. The Acute Chest Syndrome in Sickle Cell Anemia.
Acute Chest Syndrome.
Updated: January 1, 2019.
Accessed: November 27, 2019.
ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012; 307
Luciano Gattinoni, John J. Marini, Antonio Pesenti, Michael Quintel, Jordi Mancebo, Laurent Brochard. The "baby lung" became an adult. Intensive Care Med. 2016; 42
doi: 10.1007/s00134-015-4200-8 . | Open in Read by QxMD
E. A. Amsterdam, N. K. Wenger, R. G. Brindis, D. E. Casey Jr., T. G. Ganiats, D. R. Holmes Jr., A. S. Jaffe, H. Jneid, R. F. Kelly, M. C. Kontos, G. N. Levine, P. R. Liebson, D. Mukherjee, E. D. Peterson, M. S. Sabatine, R. W. Smalling, S. J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. Journal of the American College of Cardiology. 2014
doi: 10.1016/j.jacc.2014.09.017 . | Open in Read by QxMD
O’Gara PT, Kushner FG, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013; 127
doi: 10.1161/cir.0b013e3182742cf6 . | Open in Read by QxMD
Spodick DH. Acute Cardiac Tamponade. N Engl J Med. 2003; 349
doi: 10.1056/nejmra022643 . | Open in Read by QxMD
Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med. 2018; 55
doi: 10.1016/j.jemermed.2018.08.002 . | Open in Read by QxMD
Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017; 136
doi: 10.1161/cir.0000000000000509 . | Open in Read by QxMD
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol. 2013; 62
doi: 10.1016/j.jacc.2013.05.020 . | Open in Read by QxMD
Van Diepen S, Katz JN, Albert NM, et al. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017; 136
doi: 10.1161/cir.0000000000000525 . | Open in Read by QxMD
Gersh BJ, Maron BJ, Bonow RO, et al. 2011 ACCF/AHA Guideline for the Diagnosis and Treatment of Hypertrophic Cardiomyopathy: Executive Summary. J Am Coll Cardiol. 2011; 58
doi: 10.1016/j.jacc.2011.10.825 . | Open in Read by QxMD
Díez-López C, Salazar-Mendiguchía J. Clinical presentations of hypertrophic cardiomyopathy and implications for therapy. Global Cardiology Science and Practice. 2018; 2018
doi: 10.21542/gcsp.2018.19 . | Open in Read by QxMD
January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014; 64
doi: 10.1016/j.jacc.2014.03.022 . | Open in Read by QxMD
CECILIA GUTIERREZ, MD, and DANIEL G. BLANCHARD, MD. Diagnosis and Treatment of Atrial Fibrillation. Am fam physician. 2016
Karen K. Stout, Edward D. Verrier. Acute Valvular Regurgitation. Circulation. 2009; 119
doi: 10.1161/circulationaha.108.782292 . | Open in Read by QxMD
Loprinzi Brauer, et al.. Prospective Validation of the NIAID/FAAN Criteria for Emergency Department Diagnosis of Anaphylaxis. JACI: In Practice. 2016; 4
doi: 10.1016/j.jaip.2016.06.003 . | Open in Read by QxMD
Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine.
Elsevier Health Sciences
Campbell RL, Li JTC, Nicklas RA, Sadosty AT. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol. 2014; 113
doi: 10.1016/j.anai.2014.10.007 . | Open in Read by QxMD
Long B, Koyfman A, Gottlieb M. Evaluation and Management of Angioedema in the Emergency Department. Western Journal of Emergency Medicine. 2019; 20
doi: 10.5811/westjem.2019.5.42650 . | Open in Read by QxMD
Moellman JJ, Bernstein JA, Lindsell C, et al. A Consensus Parameter for the Evaluation and Management of Angioedema in the Emergency Department. Academic Emergency Medicine. 2014; 21
doi: 10.1111/acem.12341 . | Open in Read by QxMD
Hewlett JC, Rickman OB et al.. Foreign body aspiration in adult airways: therapeutic approach. J Thorac Dis. 2017; 9
doi: 10.21037/jtd.2017.06.137 . | Open in Read by QxMD
Alcaide ML, Bisno AL. Pharyngitis and Epiglottitis. Infect Dis Clin North Am. 2007; 21
doi: 10.1016/j.idc.2007.03.001 . | Open in Read by QxMD
Lindquist B et al.. Adult Epiglottitis: A Case Series. The Permanente Journal. 2016
doi: 10.7812/tpp/16-089 . | Open in Read by QxMD
Ko DR, Chung YE, Park I, et al. Use of Bedside Sonography for Diagnosing Acute Epiglottitis in the Emergency Department. Journal of Ultrasound in Medicine. 2012; 31
doi: 10.7863/jum.2012.31.1.19 . | Open in Read by QxMD
Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency Imaging Assessment of Deep Neck Space Infections. Seminars in Ultrasound, CT and MRI. 2012; 33
doi: 10.1053/j.sult.2012.06.008 . | Open in Read by QxMD
Dargan PI. An evidence based flowchart to guide the management of acute salicylate (aspirin) overdose. Emergency Medicine Journal. 2002; 19
doi: 10.1136/emj.19.3.206 . | Open in Read by QxMD
American College of Medical Toxicology. Guidance document: management priorities in salicylate toxicity. Journal of medical toxicology : official journal of the American College of Medical Toxicology. 2015; 11
doi: 10.1007/s13181-013-0362-3 . | Open in Read by QxMD
Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care. 2009; 32
doi: 10.2337/dc09-9032 . | Open in Read by QxMD
Westerberg D. Diabetic Ketoacidosis: Evaluation and Treatment. Am Fam Physician. 2013
Hampson NB, Piantadosi CA, Thom SR, Weaver LK. Practice Recommendations in the Diagnosis, Management, and Prevention of Carbon Monoxide Poisoning. Am J Respir Crit Care Med. 2012; 186
doi: 10.1164/rccm.201207-1284ci . | Open in Read by QxMD
Hampson NB. Myth busting in carbon monoxide poisoning. Am J Emerg Med. 2016; 34
doi: 10.1016/j.ajem.2015.10.051 . | Open in Read by QxMD
Updated: April 24, 2019.
Accessed: November 6, 2019.
Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016; 316
doi: 10.1001/jama.2016.9185 . | Open in Read by QxMD
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018; 49
doi: 10.1161/str.0000000000000158 . | Open in Read by QxMD
Rudkin S, Cerejo R, Tayal A, Goldberg MF. Imaging of acute ischemic stroke. Emerg Radiol. 2018; 25
doi: 10.1007/s10140-018-1623-x . | Open in Read by QxMD
DeVos E, Jacobson L. Approach to Adult Patients with Acute Dyspnea. Emerg Med Clin North Am. 2016; 34
doi: 10.1016/j.emc.2015.08.008 . | Open in Read by QxMD
Hampson NB, Courtney TG, Holm JR. Diffusion of Carbon Monoxide Through Gypsum Wallboard. JAMA. 2013; 310
doi: 10.1001/jama.2013.43127 . | Open in Read by QxMD
Frossard JL, Spahr L, Queneau PE, et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: A randomized, controlled, double-blind trial. Gastroenterology. 2002; 123
doi: 10.1053/gast.2002.34230 . | Open in Read by QxMD
Caro DA. Basic Airway Management.
: p. 1-7
American Thoracic Society. International Consensus Conferences in Intensive Care Medicine: Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Am J Respir Crit Care Med. 2001; 163
doi: 10.1164/ajrccm.163.1.ats1000 . | Open in Read by QxMD
Thim T, Krarup NHV, Grove EL, Rohde CV, Lofgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012; 5
doi: 10.2147/ijgm.s28478 . | Open in Read by QxMD
Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J.. 2017; 50
doi: 10.1183/13993003.02426-2016 . | Open in Read by QxMD
Juurlink DN, Gosselin S, Kielstein JT, et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. 2015; 66
doi: 10.1016/j.annemergmed.2015.03.031 . | Open in Read by QxMD
Stolbach AI, Hoffman RS, Nelson LS. Mechanical Ventilation Was Associated with Acidemia in a Case Series of Salicylate-poisoned Patients. Academic Emergency Medicine. 2008; 15
doi: 10.1111/j.1553-2712.2008.00205.x . | Open in Read by QxMD
Lawson-Smith P, Jansen EC, Hyldegaard O. Cyanide intoxication as part of smoke inhalation - a review on diagnosis and treatment from the emergency perspective. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19
doi: 10.1186/1757-7241-19-14 . | Open in Read by QxMD
Updated: January 1, 2019.
Accessed: November 15, 2019.
Endotracheal Intubation by Direct Laryngoscopy.
Updated: May 1, 2004.
Accessed: November 15, 2019.
Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis—a practice parameter update 2015. Annals of Allergy, Asthma & Immunology. 2015; 115
doi: 10.1016/j.anai.2015.07.019 . | Open in Read by QxMD
January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2019; 74
doi: 10.1016/j.jacc.2019.01.011 . | Open in Read by QxMD
Lewis SR, Butler AR, Parker J, Cook TM, Schofield-Robinson OJ, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review. Br J Anaesth. 2017; 119
doi: 10.1093/bja/aex228 . | Open in Read by QxMD
Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2013; 118
doi: 10.1097/aln.0b013e31827773b2 . | Open in Read by QxMD
Gregor P, Čurila K. Medical treatment of hypertrophic cardiomyopathy - What do we know about it today?. Cor Vasa. 2015; 57
doi: 10.1016/j.crvasa.2015.02.003 . | Open in Read by QxMD
Casu G, Merella P. Diuretic Therapy in Heart Failure – Current Approaches. European Cardiology Review. 2015; 10
doi: 10.15420/ecr.2015.10.01.42 . | Open in Read by QxMD
V. Sherrid M. Drug Therapy for Hypertrophic Cardiomypathy: Physiology and Practice. Current Cardiology Reviews. 2016; 12
doi: 10.2174/1573403x1201160126125403 . | Open in Read by QxMD