Severe Respiratory Distress
•Retractions and the use of accessory muscles – Retractions occur with airway obstruction (eg, asthma, chronic obstructive pulmonary disease [COPD], foreign body) and can be seen in the suprasternal, intercostal, and subcostal areas [5]. They are an ominous sign suggesting extreme respiratory distress, fatigue of the respiratory muscles, and the potential for respiratory failure. Patients with neuromuscular disease may not manifest retractions due to muscle weakness, even in the face of severe respiratory compromise.
•Brief, fragmented speech (patient isunable to answer questions with anything more than a few words), which can be quickly assessed by asking the patient to count to 10 in one breath.
•Significant tachypnea (ie, greater than 25 breaths per minute). This cutoff is not absolute, and a respiratory rate of over 20 breaths per minute should prompt a timely evaluation.
•Inability to lie supine – Many patients in respiratory distress sit bolt upright or in a tripod position. An exception is hepatopulmonary syndrome, where patients may breathe more comfortably when recumbent. (See "Hepatopulmonary syndrome in adults: Prevalence, causes, clinical manifestations, and diagnosis", section on 'Dyspnea'.)
•Profound diaphoresis,which reflects extreme sympathetic stimulation associated with severe disease (eg, myocardial infarction, severe asthma flare, diastolic cardiac dysfunction).
•Audible stridor or wheezing, which can represent upper airway obstruction or severe bronchospasm.
•Dusky skin, which indicates poor perfusion or cyanosis.
•Agitation, somnolence, or other altered mental statusin the dyspneic patient suggests severe hypoxia or hypercarbia. Patients with a depressed mental status from carbon dioxide (CO2) retention may look comfortable and lackadaisical.
Optimize arterial oxygenation (Nasal Oxygen, Intubation)
Monitor with Pulse Oximetry
Identify Life threatening Conditions
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