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Breathlessness - Management
How should I investigate people with acute breathlessness?

  • If the person does not have an indication for emergency admission, arrange investigations to identify or confirm the underlying cause of breathlessness.
  • Acute breathlessness of uncertain cause
    • Chest radiography — to look for signs of heart failure and pulmonary pathology (including pleural effusion).
    • Electrocardiogram (ECG) — to look for signs of heart failure, arrhythmia, and pulmonary embolism.
    • Spirometry or peak expiratory flow rate — to look for signs of obstructive airway disease.
    • Full blood count — to check for anaemia.
    • C-reactive protein or erythrocyte sedimentation rate (ESR) — for evidence of infection.
    • Other investigations guided by clinical findings.
  • Suspected acute asthma or an acute exacerbation of chronic obstructive airways disease (COPD)
    • Assess airways obstruction by spirometry. Airway obstruction is confirmed by a forced expiratory volume in 1 second (FEV1) less than 80% of the predicted value and FEV1/forced vital capacity (FVC) ratio less than 70%.
    • Distinguish asthma from COPD, based on:
      • Smoking history — almost always present in people with COPD.
      • Age — usually older than 35 years of age for COPD.
      • Chronic productive cough — common with COPD, uncommon with asthma.
      • Breathlessness — progressive with COPD, variable with asthma.
      • Variability of symptoms — common with asthma, uncommon with COPD.
    • If asthma and COPD cannot be distinguished based on clinical features:
      • Arrange measurements of peak expiratory flow rate (PEFR) — morning and night-time measurements, and during symptoms (to assess variability).
      • If doubt still remains, a large response (greater than 400 mL) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma; but not COPD.
      • If doubt still remains, refer the person for a specialist's opinion.
    • For people with COPD, arrange chest radiography to exclude other serious lung pathology (such as lung cancer).
  • Suspected acute exacerbation of bronchiectasis. Arrange chest radiography to exclude other causes for the symptoms. Refer the person to a respiratory specialist for confirmation of the diagnosis (by high resolution computed tomography scanning).
  • Suspected pneumonia. Arrange chest radiography if the person is older than 50 years of age and smokes (to exclude underlying cancer). For other people who are well enough to be managed in the community, chest radiography is not required to confirm the diagnosis.
  • Suspected lung/lobar collapse. Arrange chest radiography to confirm the diagnosis.
  • Suspected pleural effusion. Arrange chest radiography to confirm the diagnosis.

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