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symptom.dyspnea.ed.v1PRODUCTION
symptom.dyspnea.ed.v1

Undifferentiated dyspnea (ED)

symptomacuteundifferentiatedadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

ED dyspnea triage — onset (sudden vs subacute), quality (air hunger / wheeze / orthopnea), severity (RR / WOB / SpO2), trigger (allergen / exertion / supine) (Welch JAMA 2005)

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dyspnea characterized + onset clock started

Patient inputs (33)

Age shifts cardiogenic vs pulmonary priors; >65 raises HF and CAP priors (Heidenreich 2022)

Sex shifts COPD and asthma priors; pregnancy radically alters PE / cardiomyopathy workup

Hypotension = cardiogenic shock / massive PE / tension PTX / anaphylactic shock (ESC 2019; Heidenreich 2022)

Tachycardia non-specific; sinus tach in PE; AF rapid rate triggers HF decompensation (Heidenreich 2022)

Tachypnea (RR >24) is a sepsis-screen + PE + HF marker (ATS/IDSA 2019)

Hypoxia (<90% RA) shifts toward PE / pneumonia / PTX / HF; titrate O2 88-92% in COPD (GOLD 2026)

Fever shifts toward CAP / aspiration / atypical (ATS/IDSA 2019)

Known HF triples HF prior; informs BNP / NT-proBNP interpretation (Heidenreich 2022)

Known COPD / asthma shifts wheezing dyspnea workup toward exacerbation (GOLD 2026; GINA 2026)

Pack-years anchor COPD prior; smoking is an independent PE risk (GOLD 2026; Wells 2000)

Recent surgery / immobility / cancer / hormonal / prior VTE → Wells PE criteria (Wells 2000; ESC 2019)

Known atopy / prior anaphylaxis / drug allergies (WAO 2020)

DKA prior; uncontrolled DM with Kussmaul respirations + ketosis → endo.dka (ADA 2026)

Affects PE workup interpretation + thrombolysis decision (ESC 2019)

Orthopnea LR+ ~2.2 + PND LR+ ~2.6 for HF (Wang JAMA 2005 PMID 16204662)

Purulent sputum = bacterial pneumonia / COPD exac; pink frothy = pulmonary edema (ATS/IDSA 2019)

Pleuritic pain shifts toward PE / pneumonia / pneumothorax / pleurisy (ESC 2019 PE)

Unilateral leg pain/swelling is a Wells PE criterion (Wells 2000; ESC 2019)

Sudden = PE / PTX / anaphylaxis; subacute days-weeks = HF decompensation / pneumonia / COPD exac (Welch 2005)

Air hunger / chest tightness / wheeze / inability to lie flat — anchor cluster (Welch 2005)

ECG: AF/flutter, ischemia driving HF decompensation, S1Q3T3 / RV strain in PE, low voltage in effusion/tamponade

Pulmonary edema (cephalization, Kerley B, vascular congestion), infiltrate, pneumothorax, effusion, hyperinflation (GOLD 2026)

BNP <100 / NT-proBNP <300 rules out acute HF in dyspnea (Maisel NEJM 2002 PMID 12124404); age-adjusted NT-proBNP cutoffs apply (Heidenreich 2022)

Leukocytosis (pneumonia / sepsis); anemia (low O2 carrying — high-output dyspnea, GI bleed); eosinophilia (asthma / allergic)

Anion gap (DKA / lactic acidosis); BUN/Cr for contrast (CTPA), DOAC dose, HF perfusion; lactate for shock (SSC 2026)

Age-adjusted D-dimer rule-out for PE with low Wells (Klok 2017 PMID 24643601)

PCT supports bacterial vs viral / non-infectious dyspnea (Christ-Crain Lancet 2004 PMID 14987884)

CTPA for confirmed PE workup when Wells >4 or age-adjusted D-dimer positive (ESC 2019)

B-lines (pulmonary edema), pleural sliding (PTX), consolidation (pneumonia), pleural effusion — Lichtenstein BLUE protocol

POCUS — EF estimate, RV strain (PE), pericardial effusion (tamponade), IVC plethora (volume status)

Known allergen / sting / food / drug exposure → anaphylaxis pivot (WAO 2020)

pH + PaCO2 in COPD exac (hypercapnia → NIV); A-a gradient elevated in PE / pneumonia / ARDS (GOLD 2026)

Elevated troponin in HF decompensation, type-2 MI, RV strain from massive PE (Thygesen 2018 4th UDef MI)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateningmassive_pe_pattern
    Suspected PE + sustained hypotension (SBP <90 ×≥15 min) OR cardiac arrest with PEA/pulseless rhythm OR RV strain on POCUS with positive D-dimer (ESC 2019 PE Konstantinides PMID 35379503)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtension_pneumothorax
    Sudden pleuritic dyspnea + tracheal deviation + decreased breath sounds + hyperresonance + hemodynamic compromise — bedside diagnosis, do NOT delay for imaging (ATS/CHEST 2010)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningards_pattern
    Bilateral infiltrates on CXR + PaO2/FiO2 ≤300 + non-cardiogenic edema (BNP/NT-proBNP not consistent with HF, or echo without congestion) — Berlin criteria (Ranieri JAMA 2012; ATS/ESICM 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninganaphylaxis
    Acute onset (minutes-hours) skin/mucosal involvement (urticaria, angioedema, flushing) + ≥1 of: respiratory compromise (stridor, wheeze, hypoxia) OR hypotension OR persistent GI symptoms after likely allergen exposure (WAO 2020; Sampson NIAID criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_hf_decompensation
    BNP >400 OR NT-proBNP > age-adjusted cutoff (>450 if <50 y, >900 50-75, >1800 >75) + orthopnea/PND + pulmonary edema on CXR / B-lines on POCUS (Maisel 2002 PMID 12124404; Heidenreich 2022 PMID 35379503)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecopd_exacerbation_hypercapnic
    Known COPD + worsening dyspnea + increased sputum + pH <7.35 + PaCO2 >45 on ABG (GOLD 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_asthma_exacerbation
    Known asthma + PEF <50% personal best OR FEV1 <50% predicted + accessory muscle use + SpO2 <92% RA + speaking in short phrases (GINA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_anemia_or_gi_bleed
    Dyspnea on exertion + pallor + tachycardia + Hb drop / melena / hematemesis (ACG 2021 UGIB)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremetabolic_acidosis_dka_pattern
    Dyspnea with Kussmaul respirations + glucose >250 + anion gap >12 + ketones + bicarb <18 (ADA 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepulmonary_hypertension_decompensation
    Dyspnea on exertion + RV failure signs (JVD, peripheral edema, hepatomegaly) + echo RVSP >40 OR RV strain — group 1-5 PH (ESC/ERS 2022 PH guideline)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecommunity_acquired_pneumonia
    Fever + productive cough + dyspnea + infiltrate on CXR + leukocytosis ± elevated PCT (ATS/IDSA 2019 PMID 31573350)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildhyperventilation_anxiety_panic
    Acute dyspnea + paresthesias + perioral tingling + carpopedal spasm + low PaCO2 + normal SpO2 + normal CXR + normal BNP — diagnosis of exclusion (Welch 2005)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ed playbook — drug actions (7)

  1. 1. oxygen
    NC 2-6 L/min OR HFNC OR NIV; target SpO2 ≥94% (88-92% in COPD) • inhaled • continuous
    trigger: SpO2 <94% (or <88% in known COPD)
    GOLD 2026 — controlled O2 in COPD to avoid CO2 retention; otherwise target ≥94% in acute illness
  2. 2. albuterol + ipratropium
    rxcui 214199
    Albuterol 2.5 mg + ipratropium 0.5 mg nebulized • nebulized • q20 min × 3 then PRN
    trigger: Wheeze on auscultation (asthma / COPD exacerbation)
    GINA 2026; GOLD 2026 — SABA + SAMA combination for moderate-severe exacerbation
  3. 3. methylprednisolone
    rxcui 6902
    60-125 mg IV (or 40-60 mg PO prednisone) • IV/PO • once then taper per disposition
    trigger: Asthma or COPD exacerbation
    GINA 2026; GOLD 2026 — systemic steroids reduce relapse and shorten exacerbation
  4. 4. furosemide
    rxcui 4603
    40-80 mg IV (or 2.5× home dose if on chronic loop) • IV • once then titrate
    trigger: Acute decompensated HF with congestion + BNP/NT-proBNP elevated
    2022 AHA/ACC/HFSA HF Guideline Heidenreich PMID 35379503 — loop diuretic for congestion; chronic users need higher dose
  5. 5. epinephrine
    rxcui 3992
    0.3-0.5 mg IM (1:1000) lateral thigh • IM • q5-15 min PRN
    trigger: Anaphylaxis suspected — stridor / urticaria / hypotension / GI / known allergen exposure
    WAO 2020 — first-line; IM thigh preferred over SC or IV bolus
  6. 6. isotonic crystalloid
    500-1000 mL bolus then reassess • IV • titrate to MAP ≥65 and lung exam
    trigger: Hypotension with anaphylaxis / sepsis / massive PE; AVOID in pulmonary edema
    WAO 2020; SSC 2026 — fluid resuscitation; lung-protective in HF / ARDS axis
  7. 7. NIV (BiPAP)
    IPAP 10-12 / EPAP 5; titrate • non-invasive ventilation • continuous; reassess q1-2 h
    trigger: COPD exac with pH <7.35 + PaCO2 >45; OR cardiogenic pulmonary edema with SpO2 <90% on FiO2
    GOLD 2026 — NIV for hypercapnic COPD exac; reduces intubation and mortality (Brochard NEJM 1995)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute dyspnea presenting to ED — undifferentiated trigger for the full workup (Welch JAMA 2005); Orthopnea / PND / peripheral edema — cardiogenic dyspnea cluster (Maisel NEJM 2002 BNP; 2022 AHA/ACC/HFSA HF Heidenreich); Pleuritic dyspnea ± unilateral leg pain — PE suspicion (ESC 2019 PE Konstantinides).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Undifferentiated dyspnea (ED)** (symptom.dyspnea.ed.v1).
Phenotype framing: Acute HF (~25%) / COPD or asthma (~20%) / pneumonia (~10%) / PE (~5-7%) / pneumothorax (~1%) / anaphylaxis / anemia / metabolic acidosis (DKA / lactic) / pulmonary HTN / anxiety hyperventilation (~5-10%) — priors per Ray Eur Resp J 2006 PMID 16723034; Kelly NEJM 2005
Scope: ED dyspnea triage — onset (sudden vs subacute), quality (air hunger / wheeze / orthopnea), severity (RR / WOB / SpO2), trigger (allergen / exertion / supine) (Welch JAMA 2005)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Triage + rule-in/rule-out the 10-arm dyspnea differential (HF / PE / COPD / asthma / pneumonia / PTX / ARDS / anaphylaxis / anemia / metabolic-acidosis / pulm-HTN); stabilize oxygenation; route to downstream engine (Welch 2005; Heidenreich 2022; ESC 2019; GOLD 2026; GINA 2026; ATS/IDSA 2019)
1. oxygen NC 2-6 L/min OR HFNC OR NIV; target SpO2 ≥94% (88-92% in COPD) inhaled continuous — SpO2 <94% (or <88% in known COPD) (GOLD 2026 — controlled O2 in COPD to avoid CO2 retention; otherwise target ≥94% in acute illness)
2. albuterol + ipratropium Albuterol 2.5 mg + ipratropium 0.5 mg nebulized nebulized q20 min × 3 then PRN — Wheeze on auscultation (asthma / COPD exacerbation) (GINA 2026; GOLD 2026 — SABA + SAMA combination for moderate-severe exacerbation)
3. methylprednisolone 60-125 mg IV (or 40-60 mg PO prednisone) IV/PO once then taper per disposition — Asthma or COPD exacerbation (GINA 2026; GOLD 2026 — systemic steroids reduce relapse and shorten exacerbation)
4. furosemide 40-80 mg IV (or 2.5× home dose if on chronic loop) IV once then titrate — Acute decompensated HF with congestion + BNP/NT-proBNP elevated (2022 AHA/ACC/HFSA HF Guideline Heidenreich PMID 35379503 — loop diuretic for congestion; chronic users need higher dose)
5. epinephrine 0.3-0.5 mg IM (1:1000) lateral thigh IM q5-15 min PRN — Anaphylaxis suspected — stridor / urticaria / hypotension / GI / known allergen exposure (WAO 2020 — first-line; IM thigh preferred over SC or IV bolus)
6. isotonic crystalloid 500-1000 mL bolus then reassess IV titrate to MAP ≥65 and lung exam — Hypotension with anaphylaxis / sepsis / massive PE; AVOID in pulmonary edema (WAO 2020; SSC 2026 — fluid resuscitation; lung-protective in HF / ARDS axis)
7. NIV (BiPAP) IPAP 10-12 / EPAP 5; titrate non-invasive ventilation continuous; reassess q1-2 h — COPD exac with pH <7.35 + PaCO2 >45; OR cardiogenic pulmonary edema with SpO2 <90% on FiO2 (GOLD 2026 — NIV for hypercapnic COPD exac; reduces intubation and mortality (Brochard NEJM 1995))

Non-pharmacologic actions:
- Two large-bore IVs
- Continuous telemetry, SpO2, capnography if NIV
- Head-up positioning ≥30°; tripod position if WOB high
- Consider intubation if RR >35, exhausted accessory muscle use, GCS decline, P/F <150 despite NIV
- Activate STEMI pathway if ST-elevation overlay
- Notify ICU early if NIV not tolerated or hemodynamic instability
- Code-Sepsis bundle if SIRS + suspected pneumonia + lactate >2

Monitoring

Setting (ed) monitoring:
- Continuous SpO2, RR, ECG telemetry
- BP q15 min × 1 h then q30 min
- Serial ABG / VBG q1-2 h if NIV
- Repeat lactate q2-4 h if shock physiology
- Reassess BNP / NT-proBNP if HF rule-in pending and clinical uncertainty
- WOB assessment q15-30 min

Follow-up plan: Discharge: PCP / specialty f/u 7 d; return precautions (worsening dyspnea, fever, chest pain, syncope, hemoptysis); inhaler technique; smoking cessation; vaccinate (flu, COVID, pneumococcal — ATS/IDSA 2019; 2025 ACIP)
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Continuous SpO2 + RR + telemetry; serial ABG/VBG if NIV; serial BNP/NT-proBNP if HF axis; reassess WOB q15-30 min; capnography if NIV (GOLD 2026; Heidenreich 2022)

Disposition

Current setting: ed — Triage + rule-in/rule-out the 10-arm dyspnea differential (HF / PE / COPD / asthma / pneumonia / PTX / ARDS / anaphylaxis / anemia / metabolic-acidosis / pulm-HTN); stabilize oxygenation; route to downstream engine (Welch 2005; Heidenreich 2022; ESC 2019; GOLD 2026; GINA 2026; ATS/IDSA 2019)

Disposition criteria:
- Discharge: clear etiology, SpO2 ≥94% on RA (or baseline if COPD), stable trend, reliable follow-up ≤72 h
- Observation: moderate exacerbation responding to ED Rx, awaiting BNP trend, or low-risk PE on sPESI 0 considered for home Rx per ESC 2019
- Admit floor: HF needing IV diuresis, CAP CURB-65 ≥2, COPD exac requiring O2/steroids, confirmed PE with sPESI ≥1
- ICU: respiratory failure on NIV, intubation, massive PE on thrombolytics, anaphylactic shock, cardiogenic shock, ARDS

Escalation triggers (move to higher acuity):
- Persistent hypoxia (SpO2 <90% on FiO2 ≥0.6) → ARDS workup → route to pulm.ards.core.v1 + ICU
- PaCO2 >55 with pH <7.30 on NIV → intubation + ICU
- Massive PE with hypotension → systemic thrombolysis (alteplase 100 mg over 2 h) → route to pulm.pe.core.v1 (PEITHO Konstantinides NEJM 2014 PMID 24716681)
- Tension PTX physiology → immediate needle decompression then tube thoracostomy → route to pulm.pneumothorax.core.v1 (ATS/CHEST 2010)
- Anaphylactic shock refractory to 3 doses IM epi → epinephrine infusion + ICU → route to allergy.anaphylaxis.v1 (WAO 2020)
- Cardiogenic shock (SBP <90 with congestion) → inotropes + mechanical support → route to cardio.cardiogenic-shock.core.v1
- Severe metabolic acidosis with Kussmaul + glucose >250 + ketones → DKA pathway → route to endo.dka.core.v1

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Suspected PE + sustained hypotension (SBP <90 ×≥15 min) OR cardiac arrest with PEA/pulseless rhythm OR RV strain on POCUS with positive D-dimer (ESC 2019 PE Konstantinides PMID 35379503)
- [LIFE_THREATENING] Sudden pleuritic dyspnea + tracheal deviation + decreased breath sounds + hyperresonance + hemodynamic compromise — bedside diagnosis, do NOT delay for imaging (ATS/CHEST 2010)
- [LIFE_THREATENING] Bilateral infiltrates on CXR + PaO2/FiO2 ≤300 + non-cardiogenic edema (BNP/NT-proBNP not consistent with HF, or echo without congestion) — Berlin criteria (Ranieri JAMA 2012; ATS/ESICM 2023)

Citations

- 2022 AHA/ACC/HFSA Heart Failure Guideline (Heidenreich) + ESC 2019 PE (Konstantinides) + ATS/IDSA 2019 CAP (Metlay) + GOLD 2026 COPD + GINA 2026 Asthma + ATS/CHEST 2010 Pneumothorax + WAO 2020 Anaphylaxis + ATS/ESICM 2023 ARDS + ADA 2026 DKA + ESC/ERS 2022 PH [PMID:41959959](https://pubmed.ncbi.nlm.nih.gov/41959959/)
- Cited evidence (PMID 41883762) [PMID:41883762](https://pubmed.ncbi.nlm.nih.gov/41883762/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 2022 AHA/ACC/HFSA Heart Failure Guideline (Heidenreich) + ESC 2019 PE (Konstantinides) + ATS/IDSA 2019 CAP (Metlay) + GOLD 2026 COPD + GINA 2026 Asthma + ATS/CHEST 2010 Pneumothorax + WAO 2020 Anaphylaxis + ATS/ESICM 2023 ARDS + ADA 2026 DKA + ESC/ERS 2022 PH — PMID:41959959
  • Cited evidence (PMID 41883762) — PMID:41883762