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Effective dyspnea evaluation in urgent care requires the usage of a systems-based framework for categorizing the differential for patients with dyspnea.
Dyspnea can stem from serious conditions like pulmonary edema and pneumothorax or more benign causes like viral upper respiratory infections and asthma. However, many cases of dyspnea can be effectively assessed and managed in the urgent care (UC) setting using a systematic, systems-based approach.
Clinicians can often determine the cause based on history, exam, and testing, categorizing dyspnea into one of five main categories:
- Airway
- Pulmonary
- Cardiac
- Systemic
- Central origins
A recent article highlighted critical “can’t miss” diagnoses in urgent care, and authors guided diagnosing COPD, asthma, and pneumonia. The researchers presented a new framework simplifying the evaluation process, helping clinicians determine when reassurance or definitive treatment is appropriate. Despite limited diagnostic resources, risk stratification through clinical assessment and point-of-care (POC) tools allows for safe discharge with follow-up when appropriate. The use of this practice helps avoid unnecessary testing in low-risk patients while ensuring rare but serious conditions are not overlooked.
Evaluating Your Patient
The patient’s history should include symptom onset, triggers, associated conditions, and exposures, helping to differentiate between acute causes like pulmonary embolism (PE) or pneumothorax and more chronic conditions like heart failure or malignancy. According to the authors, clinicians must avoid cognitive biases, such as assuming a past diagnosis explains the current presentation.
The physical exam should focus on breathing patterns, lung sounds, cardiovascular signs, and systemic clues like abdominal distension or extremity swelling, which may indicate underlying conditions such as heart failure or deep vein thrombosis (DVT).
Diagnostic tools available in UC currently include chest radiography (CXR), electrocardiogram (ECG), pulse oximetry, and POC tests for blood glucose and other lab values.
CXR can reveal pneumonia, pneumothorax, or heart failure, while ECG may provide clues to cardiac-related dyspnea, though a normal ECG does not rule out serious conditions. Pulse oximetry helps assess hypoxemia, though results may be inaccurate due to poor perfusion or skin tone. If available, point-of-care ultrasound (POCUS) can enhance diagnostic accuracy, particularly in differentiating pulmonary and cardiac causes of dyspnea.
Effective use of these tools allows UC clinicians to rapidly assess and manage patients while determining the need for further intervention or emergency referral.
Categorizing Your Patient Based on Dyspnea Cause
Airway
Dyspnea with drooling or stridor suggests upper airway involvement, requiring rapid identification to prevent airway compromise. Common causes include foreign body aspiration, more frequent in children, and oropharyngeal abscesses like peritonsillar or retropharyngeal abscess, which present with fever, dysphagia, and muffled speech. Oropharyngeal aspiration, often linked to dysphagia from stroke or neuromuscular disorders, can cause pneumonitis but does not always require antibiotics. Angioedema, whether histamine- or bradykinin-mediated, can rapidly progress to airway obstruction, especially in ACE inhibitor-induced cases. Epiglottitis, once common in children, now occurs more in adults and presents with fever, muffled voice, and stridor, requiring urgent ED referral. Croup, typically viral, causes stridor and a barking cough, with corticosteroids and nebulized epinephrine as the main treatments. Vocal cord dysfunction, often mistaken for upper airway disease, presents with episodic dyspnea and noisy breathing, diagnosed via endoscopy when other causes are ruled out.
Pulmonary
Chronic obstructive lung diseases, including asthma, chronic bronchitis, and emphysema, present with dyspnea, cough, and wheezing. Asthma, common in younger patients, is triggered by allergens or infections, while COPD, linked to smoking, has a gradual onset with exacerbations often requiring antibiotics. Pneumonia, an infectious lung process, presents with cough, fever, and abnormal breath sounds, requiring antibiotic selection based on likely pathogens. Pulmonary embolism (PE) should be considered in patients with unexplained dyspnea, using risk scores and imaging for diagnosis. Pneumothorax (PTX) presents with sudden pleuritic pain and dyspnea, requiring immediate ED referral for large cases, while small, stable PTX may be monitored.
Cardiac
Cardiac causes of dyspnea include congestive heart failure (CHF), acute coronary syndrome (ACS), pericardial diseases, valvular disorders, and dysrhythmias. CHF commonly presents with dyspnea, orthopnea, and peripheral edema, with diagnosis supported by clinical signs, CXR, and BNP levels. ACS may cause dyspnea, particularly in women, diabetics, and older adults, necessitating rapid ECG assessment. Pericarditis and pericardial effusion can lead to tamponade, requiring urgent intervention. Valvular diseases like aortic stenosis and mitral regurgitation contribute to dyspnea and are diagnosed via echocardiography, with treatment options including minimally invasive valve procedures.
Systemic
Systemic illnesses causing dyspnea often involve metabolic acidosis or impaired oxygen delivery. Conditions like uremia, lactic acidosis, and ketoacidosis trigger compensatory tachypnea. Anemia, by reducing oxygen transport, can also cause dyspnea, with severity correlating to symptom intensity. Physical exam findings, such as pallor and conjunctival assessment, can aid in diagnosing anemia, though laboratory confirmation is often needed.
Central
Acute central causes of dyspnea can stem from psychogenic disorders like anxiety and PTSD or primary CNS conditions. Psychogenic dyspnea is diagnosed clinically, often triggered by specific behaviors, while testing is used to rule out medical causes. High-altitude periodic breathing, characterized by alternating apnea and hyperventilation, is more common at high elevations and can also occur in end-stage CHF with a Cheyne-Stokes pattern.
“While the causes of dyspnea are broad, many patients who report shortness of breath can be adequately assessed and triaged in the UC setting,” the authors concluded. “The systems-based framework of categorizing the differential for patients with dyspnea presented in this article offers a simple and easy-to-apply tool for UC practice.”
