ROUNDS·
Respiratory / Emergency

Dyspnea: A Systematic Approach

A systematic way to work through breathlessness, organized by system, with the bedside clues that point you in the right direction.

First: Assess Severity

Oxygen saturation, respiratory rate, work of breathing (accessory muscle use, tripod positioning), and ability to speak in full sentences. Severe distress means immediate oxygen and monitoring before a full history.

Differential by System

SystemCauses
CardiacHeart failure, ACS, arrhythmia, valve disease
RespiratoryAsthma/COPD exacerbation, pneumonia, PE, pneumothorax
OtherAnemia, metabolic acidosis, anxiety, neuromuscular weakness

Bedside Clues

Initial Workup

Chest X-ray, ABG (see ABG interpretation guide), ECG, and BNP if heart failure is being considered. D-dimer or CT angiography if PE is suspected.

Related Topics

Frequently Asked Questions

Can anxiety cause significant dyspnea?

Yes, but it's a diagnosis of exclusion — rule out organic causes first, especially in a first presentation or in a patient with risk factors for other causes.

What's the fastest bedside clue to separate cardiac from respiratory dyspnea?

JVP and leg edema point toward cardiac causes, while wheeze or focal chest findings point toward respiratory causes — though overlap is common, especially in older patients.

Does a normal chest X-ray rule out PE?

No — chest X-ray is often normal or shows only subtle findings in PE. It's mainly useful to look for alternative explanations like pneumonia or pneumothorax.