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DyspneaAPPROACH

RESPIRATORY · 19 SECTIONS

⚲

709 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Wheezing, Undifferentiated Wheezing In Infants Stridor And Upper Airway Symptoms Dyspnea Aspiration Event Cough Hemoptysis Upper Respiratory Infection Symptoms Suspected Pulmonary Embolism Presentation Smoke Inhalation Concern Smoke Exposure And Inhalational Injury

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx61

HPI overview

›Core dyspnea history

›Symptom onset context

›Pattern and trajectory

›Baseline functional status

›Prior similar episodes

›Triggering exposures

Onset

›Onset

›Sudden minutes

›Subacute hours to days

›Progressive days to weeks

›Chronic weeks to months

Provocation/Palliation

›Provocation and palliation

›Exertional

›At rest

›Positional

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Pleuritic component

›Relief with bronchodilator

›Relief with diuresis

Quality

›Quality

›Air hunger

›Chest tightness

›Inability to take a deep breath

02Alarm Features/alarm31

Immediate instability

›Time critical triggers

›Airway compromise

›Cyanosis

›Altered mental status

›Shock signs

›Severe respiratory distress

Vital sign danger thresholds

›High risk vital signs

›SpO2 less than 90 percent on room air

›Respiratory rate at least 30 per minute

›Heart rate at least 130 per minute

›Systolic blood pressure less than 90 mmHg

›Temperature at least 38.5 C

High risk symptoms

›High risk symptom patterns

›Rest dyspnea with rapid progression

›Exertional syncope

›Hemoptysis with hypoxia

›New orthopnea with frothy sputum

›Pleuritic pain with risk factors for PE

High risk exam findings

›High risk exam

›Silent chest

›Stridor

›Unilateral absent breath sounds

›Tracheal deviation

›Accessory muscle exhaustion

03Medications/meds35

Current medications

›Medication reconciliation

›Prescribed medications

›OTC medications

›Supplements and herbals

Respiratory relevant agents

›Respiratory medications

›Short acting beta agonist

›Inhaled corticosteroid

›Long acting beta agonist

›Long acting muscarinic antagonist

›Systemic corticosteroid recent use

Cardiac relevant agents

›Cardiac medications

›Diuretics

›Beta blocker

›ACE inhibitor

›ARB

›ARNI

›Mineralocorticoid receptor antagonist

›Antiplatelet therapy

›Anticoagulants

Medication changes and adherence

›Recent changes

›New start within 30 days

›Dose increase within 30 days

›Missed doses within 7 days

04Diet/diet15

Intake and hydration

›Recent intake pattern

›Poor oral intake

›Vomiting or diarrhea losses

›Dehydration symptoms

Salt and fluid balance

›Volume contributors

›High salt intake

›Excess fluid intake

›Recent diuretic reduction

Stimulants and exposures

›Dietary exposures

›Caffeine and energy drinks

›Alcohol exposure

›Aspiration risk during eating

Allergens

›Possible allergen exposure

›New foods

›Cross contamination exposure

05Review of Systems/ros31

Cardiopulmonary

›Cardiopulmonary ROS

›Chest pain

›Palpitations

›Syncope

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Edema

›Cough

›Sputum

›Hemoptysis

Infectious and inflammatory

›Infectious inflammatory ROS

›Fever

›Chills

›Myalgias

›Sore throat

›Sick contacts

Neurologic

›Neurologic ROS

›Headache

›Confusion

›Focal weakness

›Seizure

GI and aspiration

›GI aspiration ROS

›Reflux symptoms

›Vomiting

06Collateral History and Family History/chafh18

Collateral sources

›Collateral reliability

›Witness report

›EMS report

›Caregiver report

›Prior records

Family cardiopulmonary history

›Family history

›Premature coronary artery disease

›Sudden cardiac death

›Venous thromboembolism

›Asthma

›COPD

Household and environmental

›Shared exposures

›Sick contacts

›Household smoke exposure

›Carbon monoxide exposure risk

Social support and supervision

›Discharge reliability

›Ability to obtain medications

›Ability to return for worsening symptoms

07Risk Factors/rf38

Thromboembolism

›PE and DVT risks

›Recent surgery within 4 weeks

›Immobilization at least 3 days

›Prior VTE

›Active malignancy

›Estrogen therapy

›Pregnancy or postpartum within 6 weeks

›Long distance travel

Cardiac ischemia and heart failure

›Cardiac risks

›Coronary artery disease

›Diabetes mellitus (E11.9)

›Hypertension (I10)

›Chronic kidney disease (N18.9)

›Known heart failure (I50.9)

Pulmonary disease

›Pulmonary risks

›Asthma (J45.909)

›COPD (J44.9)

›Interstitial lung disease (J84.9)

›Obstructive sleep apnea (G47.33)

Infection and immunocompromise

›Infection risks

›Immunosuppressive therapy

›HIV infection (B20)

›Asplenia

›Recent influenza or COVID exposure

08Differential Diagnosis/ddx108

Life threatening

›Life threatening causes

›Pulmonary embolism (I26.99)

›Pleuritic pain

›Unexplained tachycardia

›Unilateral leg swelling

›Acute coronary syndrome (I24.9)

›Exertional symptoms

›Diaphoresis

›New ischemic ECG changes

›Acute cardiogenic pulmonary edema (I50.1)

›Orthopnea

›Rales

›S3 gallop

›Severe asthma exacerbation (J45.901)

›Silent chest

›Accessory muscle use

›Poor response to bronchodilator

›COPD exacerbation with hypercapnia (J44.1)

›Somnolence

›Rising PaCO2

›pH less than 7.35

›Tension pneumothorax (J93.0)

›Unilateral absent breath sounds

›Hypotension

›Tracheal deviation

›Pneumonia with sepsis (J18.9)

›Fever

09Past Medical History/pmh22

Cardiopulmonary conditions

›Relevant chronic diseases

›Asthma history

›COPD history

›Heart failure history

›Coronary artery disease history

›Arrhythmia history

›Pulmonary embolism history

Prior episodes and outcomes

›Prior similar presentations

›Prior ICU admission

›Prior intubation

›Prior NIV use

›Baseline oxygen requirement

Procedures and devices

›Procedures and devices

›Cardiac stents

›CABG

›Pacemaker

›ICD

›Home CPAP or BiPAP

Baseline functional status

›Baseline

›Exercise tolerance baseline

›Mobility aids

›Home supports

10Physical Exam/exam47

General and respiratory effort

›General appearance

›Ability to speak

›Accessory muscle use

›Diaphoresis

›Fatigue and exhaustion

Vital signs pattern interpretation

›Vitals pattern

›Tachypnea severity

›Fever pattern

›Hypotension pattern

›Pulse oximetry trend

Airway and upper airway

›Airway findings

›Stridor

›Voice changes

›Drooling

›Oropharyngeal edema

Lung exam

›Lung exam

›Wheeze diffuse

›Crackles

›Rhonchi

›Asymmetric breath sounds

›Percussion hyperresonance

›Prolonged expiratory phase

Cardiac and perfusion

›Cardiac and perfusion

11Lab Studies/labs31

Core labs

›Baseline labs

›CBC

›Electrolytes

›Creatinine

›Glucose

Blood gas and ventilation

›Gas exchange assessment

›VBG for pH and CO2 trend

›ABG if severe hypoxia or intubation consideration

Cardiac biomarkers

›Cardiac evaluation

›Troponin serial if ACS concern

›BNP or NT proBNP if heart failure concern

Thromboembolism testing

›PE testing

›D dimer for low risk patients

›Avoid D dimer in high pretest probability

Infection and sepsis

›Infectious evaluation

›Lactate if sepsis concern

›Blood cultures if septic shock concern

›Procalcitonin local protocol dependent

Respiratory pathogen testing

›Viral testing

›Influenza NAAT local protocol dependent

›SARS CoV 2 NAAT local protocol dependent

12Imaging/img59

Scoring Systems

›Risk and decision tools

›Wells criteria for PE

›Use when PE in differential

›Guides D dimer vs imaging

›PERC rule

›Use only if clinician gestalt low risk

›Not for pregnant patients

›YEARS algorithm

›Use to reduce CT use in suspected PE

›D dimer thresholds vary by criteria

›sPESI

›Use after PE diagnosis for risk stratification

›High risk supports admission

›CURB 65

›Use in pneumonia severity context

›Does not replace clinical judgment

MRI

›MRI options

›Cardiac MRI for myocarditis

›Consider when troponin elevated with unclear cause

›Availability and stability dependent

›MRI contraindications

›Non compatible implanted devices

›Hemodynamic instability

›CT pathways

›CT pulmonary angiography

13Special Tests/spec16

Bedside monitoring

›Monitoring adjuncts

›Continuous pulse oximetry

›End tidal CO2 if NIV or sedation

›Peak expiratory flow in asthma when feasible

Exercise desaturation

›Ambulatory assessment

›Walk test SpO2 trend

›Heart rate response

Carbon monoxide testing

›CO evaluation

›Carboxyhemoglobin level

›Pulse oximetry false reassurance

Pulmonary function context

›Spirometry context

›Not for unstable acute dyspnea

›Consider outpatient for chronic dyspnea

Allergy testing context

›Anaphylaxis support

›Serum tryptase not required for ED management

›Consider if diagnostic uncertainty and delayed sampling feasible

14ECG/ecg26

Indications

›ECG indications

›Any dyspnea with possible cardiac cause

›Any dyspnea with chest pain

›Any dyspnea with syncope

Ischemia patterns

›Ischemia findings

›ST elevation

›ST depression

›T wave inversion dynamic

›New LBBB

Right heart strain and PE patterns

›PE related patterns

›Sinus tachycardia

›New right axis deviation

›S1Q3T3

›T wave inversions V1 to V4

›RBBB new

Arrhythmias

›Arrhythmia patterns

›Atrial fibrillation with RVR

›SVT

›Ventricular tachycardia

High risk red flags

›High risk ECG features

›Wide complex tachycardia with instability

›Bradycardia with hypotension

›New ischemic changes with ongoing symptoms

15Assessment/ax25

Problem representation

›Dyspnea summary

›Severity category mild moderate severe

›Oxygenation category

›Ventilation failure risk

›Hemodynamic stability category

Working diagnoses

›Working diagnosis candidates

›Asthma exacerbation (J45.901)

›COPD exacerbation (J44.1)

›Heart failure exacerbation (I50.9)

›Pneumonia (J18.9)

›Pulmonary embolism (I26.99)

›Acute coronary syndrome (I24.9)

›Anxiety or panic (F41.0)

Risk stratification

›Risk stratification

›PE pretest probability tool selection

›Pneumonia severity tool context

›Need for NIV or intubation indicators

Complications to exclude

›Complications

›Respiratory failure

›Shock

›Arrhythmia

›Sepsis

Diagnostic uncertainty

›Uncertainty management

16Plan/plan90

Differential Management

›!Acute decompensated heart failure→›!Pulmonary embolism→›Community-acquired pneumonia→›Asthma exacerbation→›COPD exacerbation→

First 5 minutes

›First 5 minutes workflow

›High acuity triage criteria

›SpO2 less than 90 percent on room air

›Respiratory distress with fatigue

›Hypotension

›Monitoring

›Cardiac monitor

›Pulse oximetry

›Frequent BP cycling

›Access

›Two large bore IV if severe

›IO if IV failure with instability

›Oxygen escalation

›Nasal cannula

›Venturi mask

›Nonrebreather

›High flow nasal cannula local protocol dependent

›Immediate tests

›ECG within 10 minutes if cardiac concern

›CXR early if unstable or unclear cause

›Point of care glucose if altered

Airway and ventilatory support

›Respiratory support

›NIV for hypercapnic COPD exacerbation

›Consider if pH 7.25 to 7.35 with rising PaCO2

›Contraindications

›Vomiting risk

›Inability to protect airway

›Facial trauma

›Intubation triggers

›Worsening mental status

›Exhaustion

›Refractory hypoxia

›Refractory acidosis

Targeted therapy by phenotype

›Bronchospasm pathway

›Albuterol inhaled

›4 to 8 puffs MDI with spacer every 20 minutes up to 3 doses

›Continuous nebulized therapy for severe local protocol dependent

›Ipratropium inhaled

›Add for moderate to severe exacerbation

›Stop after initial hour unless ongoing severe symptoms

›Corticosteroid

›Prednisone PO 40 to 60 mg daily

›Or methylprednisolone IV 60 to 125 mg if unable to take PO

›Magnesium sulfate IV for severe asthma

›2 g IV over 20 minutes

›Avoid in significant renal failure local protocol dependent

›Pulmonary edema pathway

›NIV for cardiogenic pulmonary edema

›CPAP initial 5 to 10 cm H2O local protocol dependent

›Avoid if vomiting or hypotension

›Loop diuretic

›Furosemide IV 40 mg

›Higher dose if chronic loop use

›Vasodilator if hypertensive pulmonary edema

›Nitroglycerin IV infusion 10 to 20 mcg per minute

›Titrate every 5 minutes

›Avoid if SBP less than 100 mmHg

›Pneumonia pathway

›Antibiotics local protocol dependent

›Non severe outpatient options depend on local resistance

›Severe pneumonia early broad coverage per guideline

›Sepsis bundle if shock

›Fluids 30 mL per kg crystalloid local protocol dependent

›Vasopressor for MAP less than 65 mmHg after fluids

›PE pathway

›Anticoagulation if confirmed and no contraindication

›Heparin infusion local protocol dependent

›LMWH local protocol dependent

›Thrombolysis consideration for massive PE

›Persistent hypotension

›Cardiac arrest with suspected PE

Diagnostic sequencing

›Testing sequence

›If unstable prioritize bedside ultrasound

›If PE possible apply decision tool before D dimer

›If ACS possible troponin serial and ECG serial

Consultation

›Consult triggers

›ICU for NIV failure or intubation consideration

›Cardiology for suspected ACS with ECG changes

›Pulmonology for severe asthma or ILD flare

›Obstetrics for pregnancy with cardiopulmonary instability

Reassessment loop

›Reassessment loop

›Repeat vitals every 15 minutes in severe cases

›Repeat lung exam after therapy

›Repeat SpO2 and work of breathing after oxygen changes

›Repeat blood gas 30 to 60 minutes after NIV initiation if hypercapnia

17Disposition/dispo30

ICU criteria

›ICU indications

›Need for invasive mechanical ventilation

›NIV with persistent pH less than 7.25

›Refractory hypoxia despite high flow support

›Shock requiring vasopressors

›Massive PE or thrombolysis use

Inpatient admission criteria

›Admission indications

›New oxygen requirement

›Persistent tachypnea at least 30 per minute

›Persistent SpO2 less than 92 percent on room air with symptoms

›Pneumonia with sepsis physiology

›Heart failure needing IV diuresis

›COPD or asthma needing frequent bronchodilator beyond ED

Observation pathway criteria

›Observation options

›Moderate asthma improving after initial therapy

›Moderate COPD improving on NIV wean attempt

›Mild heart failure responding to initial diuresis

Discharge criteria

›Discharge criteria

›SpO2 at least 92 percent on room air or baseline

›Stable vital signs for 1 to 2 hours

›Minimal work of breathing

›Tolerating oral meds

›Reliable follow up and return capability

18Discharge Instructions/di16

Copy discharge instructions

›Dyspnea discharge text

›You were evaluated for shortness of breath

›Your tests today did not show an emergency cause requiring admission

›Take medications exactly as prescribed

›Use inhaler as directed if prescribed

›Avoid smoking and vaping

›Rest and gradual return to activity as tolerated

›Follow up with your clinician within 24 to 72 hours

›Return to the ER immediately for worsening shortness of breath

›Return to the ER immediately for chest pain

›Return to the ER immediately for fainting

›Return to the ER immediately for blue lips or severe weakness

›Return to the ER immediately for confusion

›Return to the ER immediately for fever with worsening breathing

›If you have a home oxygen plan follow your baseline settings

›If you are pregnant return sooner for any worsening symptoms

19References/r10

Guidelines and tools

›Key references

›Global Initiative for Asthma GINA report 2024

›Global Initiative for Chronic Obstructive Lung Disease GOLD report 2024

›European Society of Cardiology guidelines for acute pulmonary embolism 2019

›CHEST guideline and expert panel report for antithrombotic therapy for VTE disease 2021

›IDSA ATS guideline for community acquired pneumonia in adults 2019

›ACC AHA guideline for the management of heart failure 2022

›PERC rule derivation and validation Kline 2004

›YEARS study for PE diagnostic strategy van der Hulle 2017

›sPESI risk stratification for PE Jimenez 2010

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

DyspneaAPPROACH

RESPIRATORY · 19 SECTIONS

⚲

709 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx61

HPI overview

›Core dyspnea history

›Symptom onset context

›Pattern and trajectory

›Baseline functional status

›Prior similar episodes

›Triggering exposures

Onset

›Onset

›Sudden minutes

›Subacute hours to days

›Progressive days to weeks

›Chronic weeks to months

Provocation/Palliation

›Provocation and palliation

›Exertional

›At rest

›Positional

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Pleuritic component

›Relief with bronchodilator

›Relief with diuresis

Quality

›Quality

›Air hunger

›Chest tightness

›Inability to take a deep breath

02Alarm Features/alarm31

Immediate instability

›Time critical triggers

›Airway compromise

›Cyanosis

›Altered mental status

›Shock signs

›Severe respiratory distress

Vital sign danger thresholds

›High risk vital signs

›SpO2 less than 90 percent on room air

›Respiratory rate at least 30 per minute

›Heart rate at least 130 per minute

›Systolic blood pressure less than 90 mmHg

›Temperature at least 38.5 C

High risk symptoms

›High risk symptom patterns

›Rest dyspnea with rapid progression

›Exertional syncope

›Hemoptysis with hypoxia

›New orthopnea with frothy sputum

›Pleuritic pain with risk factors for PE

High risk exam findings

›High risk exam

›Silent chest

›Stridor

›Unilateral absent breath sounds

›Tracheal deviation

›Accessory muscle exhaustion

03Medications/meds35

Current medications

›Medication reconciliation

›Prescribed medications

›OTC medications

›Supplements and herbals

Respiratory relevant agents

›Respiratory medications

›Short acting beta agonist

›Inhaled corticosteroid

›Long acting beta agonist

›Long acting muscarinic antagonist

›Systemic corticosteroid recent use

Cardiac relevant agents

›Cardiac medications

›Diuretics

›Beta blocker

›ACE inhibitor

›ARB

›ARNI

›Mineralocorticoid receptor antagonist

›Antiplatelet therapy

›Anticoagulants

Medication changes and adherence

›Recent changes

›New start within 30 days

›Dose increase within 30 days

›Missed doses within 7 days

04Diet/diet15

Intake and hydration

›Recent intake pattern

›Poor oral intake

›Vomiting or diarrhea losses

›Dehydration symptoms

Salt and fluid balance

›Volume contributors

›High salt intake

›Excess fluid intake

›Recent diuretic reduction

Stimulants and exposures

›Dietary exposures

›Caffeine and energy drinks

›Alcohol exposure

›Aspiration risk during eating

Allergens

›Possible allergen exposure

›New foods

›Cross contamination exposure

05Review of Systems/ros31

Cardiopulmonary

›Cardiopulmonary ROS

›Chest pain

›Palpitations

›Syncope

›Orthopnea

›Paroxysmal nocturnal dyspnea

›Edema

›Cough

›Sputum

›Hemoptysis

Infectious and inflammatory

›Infectious inflammatory ROS

›Fever

›Chills

›Myalgias

›Sore throat

›Sick contacts

Neurologic

›Neurologic ROS

›Headache

›Confusion

›Focal weakness

›Seizure

GI and aspiration

›GI aspiration ROS

›Reflux symptoms

›Vomiting

06Collateral History and Family History/chafh18

Collateral sources

›Collateral reliability

›Witness report

›EMS report

›Caregiver report

›Prior records

Family cardiopulmonary history

›Family history

›Premature coronary artery disease

›Sudden cardiac death

›Venous thromboembolism

›Asthma

›COPD

Household and environmental

›Shared exposures

›Sick contacts

›Household smoke exposure

›Carbon monoxide exposure risk

Social support and supervision

›Discharge reliability

›Ability to obtain medications

›Ability to return for worsening symptoms

07Risk Factors/rf38

Thromboembolism

›PE and DVT risks

›Recent surgery within 4 weeks

›Immobilization at least 3 days

›Prior VTE

›Active malignancy

›Estrogen therapy

›Pregnancy or postpartum within 6 weeks

›Long distance travel

Cardiac ischemia and heart failure

›Cardiac risks

›Coronary artery disease

›Diabetes mellitus (E11.9)

›Hypertension (I10)

›Chronic kidney disease (N18.9)

›Known heart failure (I50.9)

Pulmonary disease

›Pulmonary risks

›Asthma (J45.909)

›COPD (J44.9)

›Interstitial lung disease (J84.9)

›Obstructive sleep apnea (G47.33)

Infection and immunocompromise

›Infection risks

›Immunosuppressive therapy

›HIV infection (B20)

›Asplenia

›Recent influenza or COVID exposure

08Differential Diagnosis/ddx108

Life threatening

›Life threatening causes

›Pulmonary embolism (I26.99)

›Pleuritic pain

›Unexplained tachycardia

›Unilateral leg swelling

›Acute coronary syndrome (I24.9)

›Exertional symptoms

›Diaphoresis

›New ischemic ECG changes

›Acute cardiogenic pulmonary edema (I50.1)

›Orthopnea

›Rales

›S3 gallop

›Severe asthma exacerbation (J45.901)

›Silent chest

›Accessory muscle use

›Poor response to bronchodilator

›COPD exacerbation with hypercapnia (J44.1)

›Somnolence

›Rising PaCO2

›pH less than 7.35

›Tension pneumothorax (J93.0)

›Unilateral absent breath sounds

›Hypotension

›Tracheal deviation

›Pneumonia with sepsis (J18.9)

›Fever

09Past Medical History/pmh22

Cardiopulmonary conditions

›Relevant chronic diseases

›Asthma history

›COPD history

›Heart failure history

›Coronary artery disease history

›Arrhythmia history

›Pulmonary embolism history

Prior episodes and outcomes

›Prior similar presentations

›Prior ICU admission

›Prior intubation

›Prior NIV use

›Baseline oxygen requirement

Procedures and devices

›Procedures and devices

›Cardiac stents

›CABG

›Pacemaker

›ICD

›Home CPAP or BiPAP

Baseline functional status

›Baseline

›Exercise tolerance baseline

›Mobility aids

›Home supports

10Physical Exam/exam47

General and respiratory effort

›General appearance

›Ability to speak

›Accessory muscle use

›Diaphoresis

›Fatigue and exhaustion

Vital signs pattern interpretation

›Vitals pattern

›Tachypnea severity

›Fever pattern

›Hypotension pattern

›Pulse oximetry trend

Airway and upper airway

›Airway findings

›Stridor

›Voice changes

›Drooling

›Oropharyngeal edema

Lung exam

›Lung exam

›Wheeze diffuse

›Crackles

›Rhonchi

›Asymmetric breath sounds

›Percussion hyperresonance

›Prolonged expiratory phase

Cardiac and perfusion

›Cardiac and perfusion

11Lab Studies/labs31

Core labs

›Baseline labs

›CBC

›Electrolytes

›Creatinine

›Glucose

Blood gas and ventilation

›Gas exchange assessment

›VBG for pH and CO2 trend

›ABG if severe hypoxia or intubation consideration

Cardiac biomarkers

›Cardiac evaluation

›Troponin serial if ACS concern

›BNP or NT proBNP if heart failure concern

Thromboembolism testing

›PE testing

›D dimer for low risk patients

›Avoid D dimer in high pretest probability

Infection and sepsis

›Infectious evaluation

›Lactate if sepsis concern

›Blood cultures if septic shock concern

›Procalcitonin local protocol dependent

Respiratory pathogen testing

›Viral testing

›Influenza NAAT local protocol dependent

›SARS CoV 2 NAAT local protocol dependent

12Imaging/img59

Scoring Systems

›Risk and decision tools

›Wells criteria for PE

›Use when PE in differential

›Guides D dimer vs imaging

›PERC rule

›Use only if clinician gestalt low risk

›Not for pregnant patients

›YEARS algorithm

›Use to reduce CT use in suspected PE

›D dimer thresholds vary by criteria

›sPESI

›Use after PE diagnosis for risk stratification

›High risk supports admission

›CURB 65

›Use in pneumonia severity context

›Does not replace clinical judgment

MRI

›MRI options

›Cardiac MRI for myocarditis

›Consider when troponin elevated with unclear cause

›Availability and stability dependent

›MRI contraindications

›Non compatible implanted devices

›Hemodynamic instability

›CT pathways

›CT pulmonary angiography

13Special Tests/spec16

Bedside monitoring

›Monitoring adjuncts

›Continuous pulse oximetry

›End tidal CO2 if NIV or sedation

›Peak expiratory flow in asthma when feasible

Exercise desaturation

›Ambulatory assessment

›Walk test SpO2 trend

›Heart rate response

Carbon monoxide testing

›CO evaluation

›Carboxyhemoglobin level

›Pulse oximetry false reassurance

Pulmonary function context

›Spirometry context

›Not for unstable acute dyspnea

›Consider outpatient for chronic dyspnea

Allergy testing context

›Anaphylaxis support

›Serum tryptase not required for ED management

›Consider if diagnostic uncertainty and delayed sampling feasible

14ECG/ecg26

Indications

›ECG indications

›Any dyspnea with possible cardiac cause

›Any dyspnea with chest pain

›Any dyspnea with syncope

Ischemia patterns

›Ischemia findings

›ST elevation

›ST depression

›T wave inversion dynamic

›New LBBB

Right heart strain and PE patterns

›PE related patterns

›Sinus tachycardia

›New right axis deviation

›S1Q3T3

›T wave inversions V1 to V4

›RBBB new

Arrhythmias

›Arrhythmia patterns

›Atrial fibrillation with RVR

›SVT

›Ventricular tachycardia

High risk red flags

›High risk ECG features

›Wide complex tachycardia with instability

›Bradycardia with hypotension

›New ischemic changes with ongoing symptoms

15Assessment/ax25

Problem representation

›Dyspnea summary

›Severity category mild moderate severe

›Oxygenation category

›Ventilation failure risk

›Hemodynamic stability category

Working diagnoses

›Working diagnosis candidates

›Asthma exacerbation (J45.901)

›COPD exacerbation (J44.1)

›Heart failure exacerbation (I50.9)

›Pneumonia (J18.9)

›Pulmonary embolism (I26.99)

›Acute coronary syndrome (I24.9)

›Anxiety or panic (F41.0)

Risk stratification

›Risk stratification

›PE pretest probability tool selection

›Pneumonia severity tool context

›Need for NIV or intubation indicators

Complications to exclude

›Complications

›Respiratory failure

›Shock

›Arrhythmia

›Sepsis

Diagnostic uncertainty

›Uncertainty management

16Plan/plan90

Differential Management

›!Acute decompensated heart failure→›!Pulmonary embolism→›Community-acquired pneumonia→›Asthma exacerbation→›COPD exacerbation→

First 5 minutes

›First 5 minutes workflow

›High acuity triage criteria

›SpO2 less than 90 percent on room air

›Respiratory distress with fatigue

›Hypotension

›Monitoring

›Cardiac monitor

›Pulse oximetry

›Frequent BP cycling

›Access

›Two large bore IV if severe

›IO if IV failure with instability

›Oxygen escalation

›Nasal cannula

›Venturi mask

›Nonrebreather

›High flow nasal cannula local protocol dependent

›Immediate tests

›ECG within 10 minutes if cardiac concern

›CXR early if unstable or unclear cause

›Point of care glucose if altered

Airway and ventilatory support

›Respiratory support

›NIV for hypercapnic COPD exacerbation

›Consider if pH 7.25 to 7.35 with rising PaCO2

›Contraindications

›Vomiting risk

›Inability to protect airway

›Facial trauma

›Intubation triggers

›Worsening mental status

›Exhaustion

›Refractory hypoxia

›Refractory acidosis

Targeted therapy by phenotype

›Bronchospasm pathway

›Albuterol inhaled

›4 to 8 puffs MDI with spacer every 20 minutes up to 3 doses

›Continuous nebulized therapy for severe local protocol dependent

›Ipratropium inhaled

›Add for moderate to severe exacerbation

›Stop after initial hour unless ongoing severe symptoms

›Corticosteroid

›Prednisone PO 40 to 60 mg daily

›Or methylprednisolone IV 60 to 125 mg if unable to take PO

›Magnesium sulfate IV for severe asthma

›2 g IV over 20 minutes

›Avoid in significant renal failure local protocol dependent

›Pulmonary edema pathway

›NIV for cardiogenic pulmonary edema

›CPAP initial 5 to 10 cm H2O local protocol dependent

›Avoid if vomiting or hypotension

›Loop diuretic

›Furosemide IV 40 mg

›Higher dose if chronic loop use

›Vasodilator if hypertensive pulmonary edema

›Nitroglycerin IV infusion 10 to 20 mcg per minute

›Titrate every 5 minutes

›Avoid if SBP less than 100 mmHg

›Pneumonia pathway

›Antibiotics local protocol dependent

›Non severe outpatient options depend on local resistance

›Severe pneumonia early broad coverage per guideline

›Sepsis bundle if shock

›Fluids 30 mL per kg crystalloid local protocol dependent

›Vasopressor for MAP less than 65 mmHg after fluids

›PE pathway

›Anticoagulation if confirmed and no contraindication

›Heparin infusion local protocol dependent

›LMWH local protocol dependent

›Thrombolysis consideration for massive PE

›Persistent hypotension

›Cardiac arrest with suspected PE

Diagnostic sequencing

›Testing sequence

›If unstable prioritize bedside ultrasound

›If PE possible apply decision tool before D dimer

›If ACS possible troponin serial and ECG serial

Consultation

›Consult triggers

›ICU for NIV failure or intubation consideration

›Cardiology for suspected ACS with ECG changes

›Pulmonology for severe asthma or ILD flare

›Obstetrics for pregnancy with cardiopulmonary instability

Reassessment loop

›Reassessment loop

›Repeat vitals every 15 minutes in severe cases

›Repeat lung exam after therapy

›Repeat SpO2 and work of breathing after oxygen changes

›Repeat blood gas 30 to 60 minutes after NIV initiation if hypercapnia

17Disposition/dispo30

ICU criteria

›ICU indications

›Need for invasive mechanical ventilation

›NIV with persistent pH less than 7.25

›Refractory hypoxia despite high flow support

›Shock requiring vasopressors

›Massive PE or thrombolysis use

Inpatient admission criteria

›Admission indications

›New oxygen requirement

›Persistent tachypnea at least 30 per minute

›Persistent SpO2 less than 92 percent on room air with symptoms

›Pneumonia with sepsis physiology

›Heart failure needing IV diuresis

›COPD or asthma needing frequent bronchodilator beyond ED

Observation pathway criteria

›Observation options

›Moderate asthma improving after initial therapy

›Moderate COPD improving on NIV wean attempt

›Mild heart failure responding to initial diuresis

Discharge criteria

›Discharge criteria

›SpO2 at least 92 percent on room air or baseline

›Stable vital signs for 1 to 2 hours

›Minimal work of breathing

›Tolerating oral meds

›Reliable follow up and return capability

18Discharge Instructions/di16

Copy discharge instructions

›Dyspnea discharge text

›You were evaluated for shortness of breath

›Your tests today did not show an emergency cause requiring admission

›Take medications exactly as prescribed

›Use inhaler as directed if prescribed

›Avoid smoking and vaping

›Rest and gradual return to activity as tolerated

›Follow up with your clinician within 24 to 72 hours

›Return to the ER immediately for worsening shortness of breath

›Return to the ER immediately for chest pain

›Return to the ER immediately for fainting

›Return to the ER immediately for blue lips or severe weakness

›Return to the ER immediately for confusion

›Return to the ER immediately for fever with worsening breathing

›If you have a home oxygen plan follow your baseline settings

›If you are pregnant return sooner for any worsening symptoms

19References/r10

Guidelines and tools

›Key references

›Global Initiative for Asthma GINA report 2024

›Global Initiative for Chronic Obstructive Lung Disease GOLD report 2024

›European Society of Cardiology guidelines for acute pulmonary embolism 2019

›CHEST guideline and expert panel report for antithrombotic therapy for VTE disease 2021

›IDSA ATS guideline for community acquired pneumonia in adults 2019

›ACC AHA guideline for the management of heart failure 2022

›PERC rule derivation and validation Kline 2004

›YEARS study for PE diagnostic strategy van der Hulle 2017

›sPESI risk stratification for PE Jimenez 2010

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.