Dyspnoea is a broad term that is used to describe an unpleasant awareness of one's respiratory effort and is thought of as synonymous with breathlessness (Kendall, 2020). As a presenting symptom, dyspnoea lacks specificity, therefore its assessment, management and diagnosis can be complex. Importantly, it is also recognised that the intensity of dyspnoea is only loosely associated with the severity of the underlying pathology (Santus et al, 2023), making recognition of significant illness challenging. There is a paucity of contemporary data regarding the prevalence of dyspnoea as a presenting complaint to UK emergency departments (EDs). Data from the Asia-Pacific region, although not necessarily generalisable to the UK, shows that patients with dyspnoea account for 5.2% of all presentations to the ED (Kelly et al, 2017), highlighting the significant burden on emergency care.
In this case study, the authors discuss the assessment, diagnosis and management of John Brown a 58-year-old man presenting to the ED complaining of acute dyspnoea. The complexities related to the assessment and safe management of a condition frequently seen in the ED setting by advanced clinical practitioners are highlighted. A pseudonym has been used to maintain patient confidentiality (Nursing and Midwifery Council, 2018).
Initial assessment
Initial assessment of the dyspnoeic patient should be conducted using the Airway, Breathing, Circulation method of assessment (Wyatt et al, 2020), with the addition of Disability and Exposure forming the ‘ABCDE’ approach advocated by the Resuscitation Council UK (2024). This approach allows clinicians to identify and stabilise the most life-threatening issues first before moving on (Soltan and Kim, 2016). No life-threatening issues were identified during the initial assessment of Mr Brown.
History taking
Effective history taking is of utmost importance to the diagnostic process; it is a long-held view that 70-90% of medical diagnoses can be made from the history alone (Diamond-Fox, 2021). To facilitate effective history taking, and avoid diagnostic errors, it is important to optimise data acquisition with a systematic approach to history taking (LaManna et al, 2019), such as the Calgary-Cambridge model (Silverman et al, 2013) used in this case. Data gathering should begin with an open question (Silverman et al, 2013) to elicit patient concerns without anticipating their answers (Innes et al, 2018). Open questioning increases the amount of information obtained in a history and facilitates the inclusion of a higher number of discrete symptoms (Takemura et al, 2005; Heritage and Robinson, 2006). Next, a focused review of specific symptoms should be performed. It may be helpful to use a mnemonic, such as ‘OLDCART’ (Onset, Location, Duration, Character, Aggravating/Associated factors, Relieving factors, Treatment/Timing) (Fleming et al, 2023). To aid clinical reasoning, it is important to end this phase of questioning with a systematic enquiry to ensure symptoms that may have been forgotten initially by the patient are included (Silverman et al, 2013).
This information should always be considered in the wider context of the patient's medical, social and family history (Silverman et al, 2013). Although it is useful to begin to explore this history using open questioning, patients may consider some history insignificant or irrelevant and therefore omit it. Consequently, it may be more appropriate to use closed questions (Nixon, 2013). A useful mnemonic for obtaining past medical history is ‘JAMTHREADSCa’ (Cupples, 2011). This prompts systematic coverage of a range of important common conditions: Jaundice, Anaemia, Myocardial infarction, Tuberculosis, Hypertension, Rheumatic fever, Epilepsy, Asthma, Diabetes, Stroke and Cancer. Social history is also important in all consultations. Lifestyle factors such as smoking, excessive alcohol consumption and poor diet contribute to adverse health outcomes (World Health Organization, 2024). A person's occupation can cause, or contribute to, disease (Health and Safety Executive, 2025) and a patient's home situation may influence how their condition is managed and how the plan of care is implemented.
A summary of Mr Brown's presenting history is provided in Table 1. The differential diagnoses established from his history were primarily of respiratory aetiology, likely a lower respiratory tract infection (LRTI). Given Mr Brown's history of smoking – the biggest risk factor for lung cancer (Macmillan Cancer Support, 2020) – and dust exposure (a risk factor for lung disease (Peng et al, 2020)) it was important to consider a new diagnosis of chronic obstructive pulmonary disease (COPD) or cancer. A further differential, given Mr Brown's likely work-related exposure to isocyanates (chemicals found in some paints), alongside his relatively low pack-year smoking history, was occupational asthma, a sub-type of adult-onset asthma that accounts for around one in six cases of all asthma diagnoses (Barber et al, 2022). Analysis of Mr Brown's presenting history reduced suspicion of cardiac pathology, however, this could not be completely ruled out.
| Component | Finding | |
|---|---|---|
| Presenting complaint | 4-day history of shortness of breath with associated dry cough and subjective wheeze | |
| Symptom analysis (OLDCART) | Onset | Sudden onset, no precipitating factors |
| Location | Chest | |
| Duration | 4 days | |
| Character | Present at rest, worse on exertion | |
| Aggravating/associated factors | Non-productive cough |
|
| Relieving factors | No relief of symptoms since onset | |
| Treatment/timing | Ongoing, no treatments attempted | |
| Past medical history | Rheumatic fever in childhood: no sequalae |
|
| Social history | Active smoker: 10-pack-year history |
|
| Family history | Nil known | |
| Systematic enquiry | No symptoms suggestive of cardiac pathology, including congestive cardiac failure, arrhythmia and myocardial infarction (lower limb oedema, paroxysmal nocturnal dyspnoea, orthopnoea). No cardinal symptoms of malignancy (weight loss, night sweats) or pulmonary embolism (haemoptysis, recent signs of deep vein thrombosis) | |
Physical examination
In patients presenting with dyspnoea, the physical examination is key to the diagnostic process (Coccia et al, 2016) and can lead to the correct diagnosis in 50-70% of patients without the need to obtain secondary data such as laboratory investigations or radiological imaging (Berliner et al, 2016).
Physical examination begins with a general inspection, including assessment of the hands and nails, upper and lower limbs, the neck, eyes, face and mouth. To ensure review of many key peripheral stigmata of disease it is helpful to use the ‘JACCOL’ mnemonic to check for Jaundice, Anaemia, Clubbing, Cyanosis, Oedema, and Lymphadenopathy (Bickley et al, 2021). General inspection revealed tar staining to Mr Brown's fingers consistent with tobacco use but nothing else of clinical significance. Importantly Mr Brown's jugular venous pressure was not elevated, and he had no signs of peripheral oedema, decreasing the likelihood of a right-sided cardiac pathology – such as right-sided heart failure, cor pulmonale or pulmonary hypertension (Chua Chiaco et al, 2013) – as a cause of his dyspnoea. Mr Brown had no evidence of asterixis, reducing any concern of hypercapnic respiratory failure (Ellul et al, 2017).
It is important to record vital signs, as these can give insight into a patient's condition, suggest its severity, and indicate the risk of patient deterioration (Elliott, 2021). A full breakdown of Mr Brown's vital signs, including National Early Warning Score 2 (NEWS 2) score (Royal College of Physicians, 2017), is included in Table 2. Although he was not hypoxic, Mr Brown was tachypnoeic with 28 respirations per minute. Tachypnoea is strongly associated with a risk of deterioration (Cahill et al, 2011; Resuscitation Council UK, 2024) and has been shown to be a predictive factor for deterioration, requiring ICU transfer in patients with sepsis (Boerma et al, 2017).
| Respiration rate (breaths per minute) | 28 |
| Oxygen saturations (SpO2, %) | 100 |
| Blood pressure (mmHg) | 142/83 |
| Pulse rate (bpm) | 72 |
| Level of consciousness | Alert |
| Temperature (celsius) | 36.2 |
| National Early Warning Score 2 (NEWS 2) score | 3 |
The key differentials and associated symptoms for dyspnoea are summarised in Table 3. The varied nature of these differentials necessitates examination of both the respiratory and cardiovascular systems. As these examinations share many similarities it is appropriate to complete both concurrently.
| Cough | Coarse crackles | Bilateral wheeze | Bilateral fine crackles | Focal reduced air entry | Purulent or copious sputum | |
|---|---|---|---|---|---|---|
| Left-sided heart failure | No | No | Possible | Yes | No | No |
| Chronic obstructive pulmonary disease | Yes | Yes | Yes | Possible | No | Yes (in acute exacerbation) |
| Asthma | Yes | No | Yes | No | No | Possible |
| Pneumonia | Yes | Yes | No | No | Possible | Yes |
| Pneumothorax | Possible | No | No | No | Yes | No |
| Acute pulmonary embolism | Possible | Possible | No | Possible | No | No |
Source: adapted from Hopcroft and Forte, 2020
Mr Brown's chest showed no scars indicative of previous cardiac or respiratory surgery, no thoracic abnormality such as the ‘barrel chest’ seen in COPD (Sarkar et al, 2019), and no nodules suggestive of underlying cancer (Innes et al, 2018) or other skin lesions. Although Mr Brown was tachypnoeic, inspection showed no evidence of accessory muscle use, suggesting that he was adequately meeting his ventilatory demand (Cahill et al, 2011).
Palpation elicited no chest wall pain, no shift of the trachea suggestive of tension pneumothorax or lobar collapse and no subcutaneous emphysema; there was normal and equal chest expansion bilaterally (Innes et al, 2018). Mr Brown had a normally placed apex beat and no cardiac heaves or thrills suggestive of ventricular hypertrophy or aortic stenosis (Innes et al, 2018).
Following palpation, percussion was used to assess for the presence of any altered density in the lung tissue. This includes signs that may indicate a build-up of fluid, or the presence of abnormal amounts of air, such as in a pneumothorax or hyperinflation in COPD (Morgan, 2022). Mr Brown had dull notes of percussion to his right lung base, increasing suspicion of a respiratory pathology being the cause of his symptoms.
Finally, auscultation was performed of the bilateral lung fields and of the four cardiac regions. Auscultation revealed expiratory wheeze in the upper and mid zones. The presence of wheeze suggests airflow obstruction due to bronchoconstriction (Chou et al, 2022) and is often present in airway disease such as COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2024) and asthma (National Institute for Health and Care Excellence (NICE) et al, 2024). The possible presence of consolidation was further assessed using vocal resonance, a technique where the patient repeats a phrase, at both normal and low volume, during auscultation of the lung regions. If there is consolidation present then ‘whispering pectoriloquy’ is heard due to increased transmission of sounds (Innes et al, 2018). Cardiac auscultation revealed no cardiac murmur.
Given the presence of wheeze, tachypnoea and non-productive cough, alongside the lack of fever and tachycardia that would suggest acute infection, it was felt that Mr Brown was most likely experiencing a non-infective exacerbation of undiagnosed COPD. Ongoing consideration was also given to a differential diagnosis of occupational asthma. These diagnoses were supported by Mr Brown's smoking history and his history of occupational dust and isocyanate exposure.
Investigations and ongoing management with recommendations for future practice
Investigations
A chest radiograph remains the cornerstone of initial investigation of dyspnoea and is often considered the only imaging necessary for making a diagnosis (Milos et al, 2023). In Mr Brown's case, a chest X-ray was performed to investigate for consolidation suggestive of pneumonia, lung mass suggestive of malignancy, and chronic changes such as hyperinflation, suggestive of obstructive airways disease (Kendall, 2020). Although chest X-rays are routinely performed, evidence suggests that accurate interpretation of the chest radiograph is lacking. A small initial audit performed by Satia et al (2013) as part of a wider study, found that clinicians correctly identified acute abnormalities in only 43% of cases. Although this evidence quality is limited by a small and homogenous sample, it does raise concerns for the accuracy of chest X-ray interpretation. To improve future practice, it is likely to be worthwhile to further study this area and use the data obtained to guide education of both current and future clinicians. Mr Brown's chest X-ray showed no evidence of abnormalities.
Bloods were taken from Mr Brown, including a full blood count (FBC), renal/liver/urea profile (RLU), C-reactive protein (CRP), and a venous blood gas (VBG). These showed a raised CRP – indicative of non-specific systemic inflammation (Lab Tests Online, 2020), and possibly a sign that Mr Brown had undiagnosed COPD (Leuzzi et al, 2017). However, these tests demonstrated no other abnormalities. The lack of leucocytosis reduced suspicion of a bacterial infection (Lab Tests Online, 2025). Mr Brown's eosinophil count was within the normal range, necessitating further investigation via fractional exhaled nitric oxide (FeNO) testing to definitively rule out occupational asthma (NICE et al, 2024), a test that can be difficult to obtain in the ED due to the need for specialist equipment.
Although guidelines recommend arterial blood gas (ABG) measurement as a point-of-care test to investigate suspected COPD exacerbations (NICE, 2019) and rapidly assess blood pH, lactate and electrolyte levels, there is strong evidence from both meta-analyses (Bingheng et al, 2019) and cohort studies (McKeever et al, 2016) that shows good agreement between values obtained from VBG and ABG sampling, providing the patient is not in a state of systemic shock. This evidence, alongside the fact that VBG sampling is considerably less painful for the patient, and much less technically difficult to obtain, provides a strong argument for VBG sampling as a first-line procedure in patients not in systemic shock. Mr Brown's VBG showed a normal pH, normocapnia, and a non-raised lactate.
To further investigate the severity of Mr Brown's airflow obstruction, a peak expiratory flow rate (PEFR) was recorded. PEFR measures how quickly air can be blown out from the lungs and can indicate whether the airways are narrowed. Mr Brown had a PEFR of 160 L/min, well below his expected level of 560 L/min. The use of PEFR in suspected COPD is disputed in the available literature. The GOLD report (2024) suggested that, although PEFR is a sensitive measurement that can rule out airway narrowing if within normal limits, it has low specificity, and is unable to differentiate between obstructive lung diseases, such as COPD, or restrictive lung disease. Conversely, Ronaldson et al (2018) found that PEFR performed well for the early identification of COPD. However, it is worth noting that Ronaldson's study had a relatively small sample size and was performed in a primary care setting, and therefore may not be generalisable to practice in the ED. The evidence is, however, in agreement that the gold standard for investigation of COPD is spirometry and measurement of forced expiratory volume in 1 second (FEV1), therefore in this case PEFR was used as a baseline measurement from which to assess treatment effect.
Pharmacological management
Initial pharmacological management of suspected COPD exacerbation includes use of inhaled short-acting bronchodilator therapy (NICE, 2019) to reduce airflow obstruction. NICE et al (2024) guidance is that the bronchodilator therapy of choice is the beta-2 agonist salbutamol. The GOLD report (2024) suggested a preference for nebuliser therapy; however, bronchodilators can also be delivered via metred-dose inhaler with or without a spacer (Hess, 2023). Mr Brown was trialled with inhaler and spacer; however, he was unable to produce an effective technique and therefore he was given bronchodilator therapy via a nebuliser.
A key element of the pharmacological treatment of COPD exacerbations is the use of corticosteroids. Corticosteroids have clear benefits to lung function, breathlessness and treatment success (GOLD, 2024). Joint guidance from the European Respiratory Society (ERS) and the American Thoracic Society (ATS) (Wedzicha et al, 2017) on management of COPD exacerbations also supports the use of corticosteroids. However, this guidance does acknowledge a limited evidence base regarding their use.
Although a 5-day course of prednisolone is recommended by GOLD (2024), and well supported by evidence in the form of both a randomised control trial (RCT) (Leuppi et al, 2013) and a meta-analysis (Walters et al, 2018) the appropriate dosage of prednisolone for COPD exacerbations remains a matter of debate. This is reflected in the NICE guidance for managing COPD exacerbations, which recommends a 5-day course of 30 mg prednisolone (NICE, 2019) rather than the 40 mg dose recommended by GOLD (2024). Although there is little evidence differentiating between these doses, evidence does show that lower cumulative corticosteroid doses are associated with better treatment outcomes and lower treatment failure rates (Hemenway and Terry, 2017; Pu et al, 2021). Further research is needed to compare dosages using RCTs. There is growing evidence concerning the use of nebulised budesonide as an alternative to systemic corticosteroids such as prednisolone. A meta-analysis from Gu et al (2020) reviewed data from six studies, including 867 total participants, concluding that nebulised budesonide was not inferior to systemic corticosteroids, and carried a lower risk of adverse effects such as hyperglycaemia. This study is, however, limited by the low number of included articles it references and the lack of long-term follow-up data included in the underlying trials. Definitive conclusions about the efficacy and long-term safety of nebulised budesonide therefore cannot be drawn. However, this area does warrant further investigation. The undertaking of large scale RCTs would likely be worthwhile and have a positive influence on future practice.
Smoking cessation
Smoking is one of the most prevalent risk factors for COPD, with around 90% of cases being associated with tobacco use (NICE, 2025). Smoking cessation is associated with decreased disease progression, improvement of symptoms and a reduction in mortality rates (Tashkin, 2021). Therefore, one of the most important non-pharmacological interventions for COPD is the provision of smoking-cessation advice. Despite its importance, clinicians attempting to deliver smoking-cessation advice in the ED still face many barriers, including a lack of organisational support and absence of standardised practices (Rush et al, 2018). The Cessation of Smoking Trial in the Emergency Department (CoSTED) (Notley et al, 2023) recruited 972 individuals across six NHS trusts to survey the efficacy and cost-effectiveness of an opportunistic smoking-cessation intervention, including provision of an e-cigarette, in the ED. This study showed significantly increased rates of sustained smoking abstinence at 6 months in the intervention group when compared to those individuals who were only signposted to local stop-smoking services. These results suggest that smoking cessation in the ED can reach population groups that are unlikely to engage routinely with stop-smoking services (Pope et al, 2024). This study is highly generalisable given the robust sample size and UK multi-centre nature and has significant implications for ED practice. However, Pope et al (2024) highlighted the need for dedicated staff to undertake this intervention to avoid over-burdening clinical staff.
Ongoing management
Unfortunately, Mr Brown did not significantly improve with initial management in the ED and was subsequently referred to the acute internal medical team for further review. Although his ongoing care is outside the scope of this case study, it is worth noting that he was discharged following a brief admission with a course of prednisolone, a salbutamol inhaler, and a referral for lung function testing to further investigate his symptoms and differentiate between the differentials of COPD and occupational asthma.
Conclusion
This case study has highlighted the importance of comprehensive history taking, structured exploration of symptoms, and thorough physical examination, particularly when dealing with a common, non-specific presenting complaint such as dyspnoea.
Although well established, it is clear that the assessment and management of dyspnoea and COPD could be advanced. This case study has highlighted exciting ongoing research alongside areas that require further investigation through large-scale RCTs.