Shortness of breath (dyspnoea) is a terrifying symptom experienced by patients and is a common reason for presentation to Emergency Departments. There are a wide range of causes including flair up due to chronic conditions such as asthma, heart failure, chronic lung disease or liver or kidney failure. Acute conditions such as a collapsed lung, chest infection (including pneumonia), trauma (including fractured ribs), airway blockage or an allergic reaction can also be the cause.
There is significant knowledge about patients who are admitted to hospital with common causes, however there is little conclusive information about Dyspnoea as a symptom, the distribution of causes, the proportion of patients requiring admission and whether treatment complies with evidence-based guidelines.
A recent pilot study in Europe found that 53 per cent of patients had a respiratory cause for symptoms, 22 per cent had a cardiac cause, and 15 per cent had both cardiac and respiratory components. Almost two-thirds were admitted to hospital with over one-third discharged from ED. However, in many ways, the study raised more questions than it answered. The study was also too small to comment on adherence to evidence-based guidelines.
For that reason, a larger EuroDEM (digital elevation model) study is planned for 2014. The study will be complemented by the Australia, Asia and New Zealand Dyspnoea Departments of Emergency Medicine (AANZDEM) which will collect data from a different region with different systems of care. It will focus on the range of causes, variation over seasons and geographical areas, and compliance with recommended treatments.
A total of 3044 patients were studied. Patients with dyspnoea made up 5.2% of ED presentations, 11.4% of ward admissions and 19.9% of intensive care unit (ICU) admissions. The most common diagnoses were lower respiratory tract infection (20.2%), heart failure (14.9%), chronic obstructive pulmonary disease (13.6%), and asthma (12.7%). Hospital ward admission was required for 64% of patients with 3.3% requiring ICU admission. In-hospital mortality was 6% .
Dyspnoea was found to be a common symptom in ED patients contributing substantially to ED, hospital, and ICU workload. It was also associated with significant mortality. There were a wide variety of causes however chronic disease accounts for a large proportion.
In the Asia Pacific region, heart failure was a common diagnosis among patients presenting to the ED with a principal symptom of dyspnoea. Admission rates were high and ED diagnostic accuracy was good. Despite the seemingly suboptimal adherence to investigation and treatment guidelines, patient outcomes were favourable compared with other registries.
- Laribi S., Keijzers G., van Meer O., Klim S., Motiejunaite J., Kuan W.S., Body R., Jones P., Karamercan M., Craig S., Harjola V.P., Holdgate A., Golea A., Graham C., Verschuren F., Capsec J., Christ M., Grammatico-Guillon L., Barletta C., Garcia-Castrillo .L, Kelly A.M.; AANZDEM and EURODEM study groups, 'Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region', Eur J Emerg Med. 2018 Aug 30. doi: 10.1097/MEJ.0000000000000571. [Epub ahead of print]
- Kuan WS, Craig S, Kelly AM, Keijzers G, Klim S, Graham CA, Jones P, Holdgate A, Lawoko C, Laribi S., 'Asthma among adult patients presenting with dyspnea to the emergency department: An observational study', Clin Respir J., 2018 Jun;12(6):2117-2125. doi: 10.1111/crj.12782. Epub 2018 Mar 24.
-Kelly AM, Holdgate A, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Lawoko C, Laribi S., 'Epidemiology, treatment, disposition and outcome of patients with acute exacerbation of COPD presenting to emergency departments in Australia and South East Asia: An AANZDEM study, Respirology, 2018 Jul;23(7):681-686. doi: 10.1111/resp.13259. Epub 2018 Feb 2.
-Keijzers G, Kelly AM, Cullen L, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Holdgate A, Lawoko C, Laribi S., 'Heart failure in patients presenting with dyspnoea to the emergency department in the Asia Pacific region: an observational study', BMJ Open, 2017 Feb 28;7(2):e013812. doi: 10.1136/bmjopen-2016-013812.- Kelly, A.M., Keijzers, G., Klim, S., Graham, C.A., Craig, S., Kuan, W.S., Jones, P., Holdgate, A., Lawoko, C. and Laribi, S., “An Observational Study of Dyspnea in Emergency Departments: The Asia, Australia, and New Zealand Dyspnea in Emergency Departments Study (AANZDEM), Academic Emergency Medicine, 2017;24(3):328-336. doi: 10.1111/acem.13118.
- Keijzers G., Kelly A., Cullen L., Klim S., Graham C., Craig S., Kuan W.S., Jones P., Holdgate A., Lawoko C. and Laribi S., “Heart failure in patients presenting with dyspnoea to the emergency department in the Asia Pacific region: an observational study”, BMJ Open 2017;7:e013812. doi:10.1136/bmjopen-2016-013812
- Kelly A.M., Holdgate A.,Keijzers G., Klim S., Graham C.A., Craig S., Kuan W.S., Jones P., Lawoko C., Laribi S., & AANZDEM study group, “Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: an observational study”, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2016; 24:113. doi:10.1186/s13049-016-0305-5.
- Kelly AM, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Holdgate A, Lawoko C, Laribi S; AANZDEM Study Group, “Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study: Rationale, design and analysis”, Emerg Med Australas, 2015 Jun;27(3):187-91. doi: 10.1111/1742-6723.12397.
Prof Gerben Keijzers
Prof Anne-Maree Kelly
Dr Fran Kinnear
Dr Chris May
Dr Jeremy Furyk
Dr Ogilvie Thom
Dr Shane Martin
Dr Ulrich Orda
Dr Richard Stone
Dr Alison Ryan
Dr Jae Thone
Dr Robert Eley
Dr David Rosengren
Dr Douglas Morel