Dyspnea has many causes but can be divided into general categories (Table- 58-1). Because of its mainly subjective component, the presence or degree of dyspnea is difficult to measure, although categorical scales (e.g., the Borg scale) and visual analogue scales can be used in individual patients to gauge changes in the degree of distress in response to therapy. The initial assessment of any patient with dyspnea should be directed toward identifying imminent respiratory failure. The physician should specifically evaluate for tachypnea, tachycardia, stridor, and use of the accessory respiratory muscles, including the sternocleidomastoid, sternoclavicular, and intercostals. Other signs and symptoms of imminent respiratory failure are inability to speak due to the breathlessness, agitation or lethargy due to hypoxia, and paradoxical abdominal wall movement (abdominal wall retracts inward) with inspiration, indicating diaphragmatic fatigue. In patients with any of these signs or symptoms, oxygen should be administered and the need for airway control and mechanical ventilation must be anticipated. Lesser degrees of dyspnea allow for a more detailed medical history, physical examination, and indicated ancillary tests.
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