Special Report

Reduce risks in patients with shortness of breath

by Jorge A. Matinez, MD, JD

The checklist below, developed by Jorge A. Martinez, MD, JD, Director of Clinical Emergency Medicine Services at Charity Hospital and Professor of Clinical Medicine at Louisiana State University School of Medicine, both in New Orleans, reminds us of potential steps or options that should be considered to reduce risks when caring for patients with shortness of breath in the emergency department (ED).

  • Carefully listen to the patient. Allow the patient to describe their illness and symptoms in their own words. Seek additional information from family, caretakers, or paramedical personnel as needed.
  • Be careful not to overlook the nurses' notes and emergency medical services' documents that contain supplemental information regarding the patient's medical history and present clinical presentation.
  • Don't forget the basics — make sure your patients with severe shortness of breath rapidly receive supplemental oxygen, are placed on a cardiac monitor, have an intravenous line established, and have a pulse oximeter applied.
  • Pay attention to the patient's vital signs. Repeat them liberally or follow the monitored vital signs closely to look for early indicators of change in the patient's condition.
  • Initially, the physical examination should be aimed at finding physical signs and manifestations consistent with disease or injury of the respiratory tract. In the absence of such findings, the physical examination should be expanded to uncover physical signs and manifestations that suggest which organ system, environmental factor, or injury is causing or contributing to the shortness of breath.
  • Carefully and thoughtfully develop your differential diagnosis based on your historical information and physical examination.
  • Based on your most likely diagnoses with an eye towards the life-threatening conditions, prioritize laboratory and radiological studies.
  • If the cause of the shortness of breath can be addressed and the respiratory status stabilized in the ED, the patient may be discharged. In addition to written instructions and appropriate medications to manage the non-life-threatening cause of the shortness of breath, instruct patients to return to the ED if the outpatient treatment fails or if the shortness of breath worsens. For those patients with potential high risk or life-threatening etiologies, consultation should be obtained and hospital admission to the appropriate unit should be carried out.

ED cases involving shortness of breath

Moore v. St. Joseph's Hospital, 538 S.E.2d 714 (W. Va. 2000).

On March 28, 1995, the patient was taken to St. Joseph's ED complaining of muscular and skeletal pain, and was treated conservatively and released. Two days later, the patient was taken back to the ED complaining of sweating and shortness of breath, and was diagnosed with pneumonia, treated and released.

On April 3, 1995, the patient was taken to St. Joseph's ED for a third time, and during the visit, he again complained of sweating and shortness of breath. At that time he was diagnosed as suffering from congestive heart failure, and was transferred to another hospital the following day, and died two days later. The cause of death was attributed to pulmonary embolism.

A wrongful death action was filed alleging negligence by St. Joseph's for failing to diagnose and treat the patient for pulmonary embolism. The case was heard by a jury, who returned a verdict finding St. Joseph's 75% liable for the death of the patient. The jury awarded the patient's wife $50,000 in non-economic damages and $100,000 in economic damages.

Possible lessons learned:

  • Consider patients who return to the ED with the complaint of ongoing shortness of breath at high risk for a wrong diagnosis or inadequate initial therapy. Be sure to carefully evaluate these patients as a new patient and search diligently for an occult pulmonary or nonpulmonary cause of shortness of breath.
  • Always repeat the history and physical examination while paying special attention to changes in the patient's symptoms and clinical examination.
  • Don't forget that a pulmonary embolus can parade as more common conditions such as hyperventilation syndrome or asthma and should be considered in cases where the cause of shortness of breath is not apparent after repeat laboratory and radiological studies.

Holly v. Huntsville Hospital, 865 So.2d 1177 (Ala. 2003).

A mother took her 11-month-old son to the ED at Huntsville Hospital because he had a high fever, a rapid pulse rate, and trouble breathing. The ED physician treated the child for croup, observed him for three hours, and gave the mother a prescription and discharged the child.

While the mother was at the pharmacy getting the prescription filled, the child suffered a respiratory and cardiac arrest. Emergency medical technicians transported the child to Huntsville Hospital, where he was pronounced dead. An autopsy indicated that the child died of necrotizing tracheobronchitis, a severe infection of the trachea and bronchi that obstructed his airway.

The jury returned a verdict in favor of the defendants. The plaintiffs moved for a new trial. The trial court denied the motion and entered a judgment on the jury verdict in favor of the defendants. The plaintiffs appealed the trial courts denial of a new trial arguing that the trial court erred in 1) excluding the plaintiffs' experts' testimony to standard of care and breach of that standard, and 2) in instructing the jury on the plaintiffs' experts' competency and on the applicable standard of care.

The Alabama Supreme Court ruled that the trial court erred in instructing the jury that the plaintiffs' experts were not qualified to testify to standard of care and breach of that standard. The Court also ruled that the trial court erred in instructing the jury that the standard of care applicable to the defendant doctor was the standard of care for family practice physicians rather than physicians practicing emergency medicine.

Finally, the Court held that the trial court erred in denying plaintiff's motion for a new trial and ordered a new trial on the merits of the case. In a subsequent trial, the jury returned a verdict in favor of the plaintiffs. The defendants moved for a new trial, which was granted by the trial court. The trial court's decision was affirmed by the Alabama Supreme Court in 2005, and the case has been remanded back to the trial court for a new trial.

Possible lessons learned:

  • Shortness of breath in children has many benign etiologies, but don't forget life-threatening conditions such as bacterial tracheitis, myocarditis with congestive heart failure, overwhelming pneumonia, toxic exposure/ingestion, anaphylaxis, or aspirated foreign body.
  • A detailed history should be taken from family members or friends who witnessed the child's shortness of breath. Questions may include:
    What was the child doing when he developed the shortness of breath? (Keep in mind the possibility of a foreign body aspiration.)
    Was the onset of shortness of breath acute or gradual?
    Does the child have any medical illnesses, or has he or she undergone surgical procedures?
    What medications is the child taking? (This may help clarify if the child has any underlying medical problems.)
    Does the child have any allergies?
    Has the child developed fever, choking, cough, nausea, vomiting, diarrhea, or a change in mental status or level of consciousness?
    Does the child make any noises while breathing? (Clarify if patient has stridor or wheezing or both.)
  • The physical examination must include visualization of the child's nasopharyngeal airway, mouth, throat (with caution if epiglottis is suspected). The chest should be inspected for intercostal retractions and accessory muscle use. The physical examination must also include meticulous auscultation of the neck, trachea, and chest.
  • Monitor the child's oxygen saturation and administer oxygen liberally.
  • Consider a soft-tissue lateral X-ray of the neck if the upper airway is involved. (If epiglottitis is a consideration, the X-ray should be performed as a portable or the child should be accompanied by the physician to the radiology suite and airway equipment goes along.)
  • Monitor carefully the child's overall clinical condition and vital signs. If the child's condition and vital signs do not stabilize with treatment, the child should be admitted for further evaluation, treatment, and consultation.