Shortness Of Breath

Give 0.3–0.5 mg IM into the anterolateral thigh.

Use 1 mg/mL solution: 0.3–0.5 mL.

Repeat every 5–10 minutes for persistent symptoms. Epinephrine Labeling.

There is no absolute contraindication to indicated IM epinephrine. WAO 2020.

See Pediatric IM Dosing.

Start at 2 mcg/min IV; titrate to respiratory and circulatory response. The AAAAI/ACAAI parameter describes a 2–10 mcg/min regimen. AAAAI/ACAAI 2020.

Use the institutional concentration / titration protocol, an infusion pump, and a dedicated IV line. Monitor ECG, SpO₂, and frequent BP.

Continue IM epinephrine for persistent compromise while preparing the infusion. No routine IV boluses with a pulse. RCUK 2021 — Infusion Protocol.

Stop the suspected trigger; establish IV access and monitoring.

Give oxygen for respiratory distress / hypoxemia.

Give IV crystalloid for hypotension; reassess perfusion. WAO 2020.

Progressive upper-airway swelling → early expert airway help.

Keep hypotensive patients supine; adjust position for respiratory distress. No standing or walking during the acute reaction. RCUK 2021.

Start CPR and follow the adult cardiac-arrest pathway.

Epinephrine 1 mg IV / IO every 3–5 minutes. Do not escalate routinely to 3-mg or 5-mg doses. AHA 2025 — ALS.

Give isotonic IV fluids for anaphylaxis-associated circulatory collapse; reassess rather than targeting a fixed total volume.

Consider extracorporeal CPR for selected refractory arrests where available. AHA 2025 — Anaphylaxis.

Confirm resolution, stable vital signs, and safe follow-up.

Provide rescue epinephrine and demonstrate device use; ensure access to a second dose. RCUK 2021.

Give a written action plan, recurrence precautions, trigger-avoidance advice, and allergy follow-up.

Severe symptoms, incomplete response, or recurrence after rescue epinephrine → emergency medical care. AAAAI/ACAAI 2023.

Anaphylaxis or life-threatening histamine-mediated swelling → IM epinephrine. See Anaphylaxis.

If the mechanism is uncertain and anaphylaxis remains possible, give indicated epinephrine while managing the airway. SAEM/ACAAI 2014.

Treat residual hives / itching with an H1 antihistamine after stabilization; it does not replace epinephrine or airway management. See Anaphylaxis — Adjuncts.

ACE inhibition reduces bradykinin breakdown. Swelling can begin months or years after starting treatment and is not dose-dependent. AAEM — ACE Inhibitors.

Stop the ACE inhibitor permanently. Document the reaction; avoid all ACE inhibitors.

No established benefit from routine epinephrine, antihistamines, or steroids in clear ACE-inhibitor angioedema.

Icatibant, ecallantide, C1-inhibitor concentrate, tranexamic acid (TXA), and fresh frozen plasma (FFP) have insufficient evidence for routine use. Do not delay airway control for a drug trial. AAEM 2020.

Give on-demand treatment early according to the patient’s plan, such as C1-inhibitor concentrate or icatibant.

These therapies have established efficacy in HAE with C1-inhibitor deficiency / dysfunction; that benefit cannot be assumed for ACE-inhibitor angioedema.

FFP is a fallback when specific treatment is unavailable; consider transfusion risks and reports of worsening swelling.

Upper-airway involvement requires urgent airway assessment despite treatment. US HAEA 2020 — Acute Treatment.

Assess speech, effort, air movement, consciousness, SpO₂, pulse, and BP; compare with baseline.

Start inhaled bronchodilators and controlled oxygen. Look for pneumonia, heart failure, pneumothorax, PE, or ischemia. See Assessment / Severity.

Apnea, exhaustion with weakening effort, inability to protect the airway, or rapid deterioration.

Intubation when necessary; do not prolong failing NIV. Continue medical treatment during preparation. See Intubation.

Respiratory acidosis with increased effort → bilevel NIV / BiPAP, unless immediate intubation is required.

Bronchodilators + systemic steroids + antibiotics when ventilatory support is required.

Reassess effort, consciousness, and gas exchange early. pH <7.25 alone does not mandate intubation. See NIV.

Inhaled albuterol ± ipratropium; oral steroids for a significant exacerbation.

Supplemental oxygen to 88–92%; antibiotics according to indications.

Persistent distress / poor response → blood gas, diagnostic reassessment, and escalation.

Discharge: Sustained improvement, oxygen near baseline, safe home plan.

Monitored Admission: Persistent symptoms, increased oxygen, or frequent treatment.

ICU Admission: Worsening respiratory failure, high-risk NIV, or invasive ventilation.

See Disposition.

Increased dyspnea, cough, or sputum compared with baseline supports an exacerbation.

Pneumonia, heart failure, PE, pneumothorax, and cardiac ischemia may mimic or accompany it.

Chest pain, focal findings, disproportionate hypoxemia, or poor response warrants targeted reassessment. Rome Proposal 2021.

Assess accessory muscle use, respiratory rate, speech, air entry, wheezing, and expiratory time.

Exhaustion, paradoxical breathing, weakening effort, altered consciousness, or hemodynamic instability signals high risk.

Blood gases distinguish compensated hypercapnia from acute respiratory acidosis. Chronic CO₂ elevation alone does not establish acute ventilatory failure.

The algorithm prioritizes immediate respiratory-support decisions; the classification below describes attack severity. Rome 2021.

Establish usual oxygen requirement, function, prior NIV / intubation, recent admissions, and current inhalers.

Clarify goals of care and the escalation plan early, especially when NIV may be the treatment ceiling. BTS/ICS 2016.

Titrate supplemental oxygen to SpO₂ 88–92%. Avoid unnecessary hyperoxia; reassess ventilation as well as saturation.

Correct life-threatening hypoxemia immediately; titrate after stabilization.

Prefer air-driven nebulization with separately titrated oxygen when available.

• Journal Club — Austin 2010: Austin’s prehospital trial found mortality of 9% with high-concentration oxygen versus 2% with titrated oxygen in the confirmed-COPD subgroup. This was not a comparison of HFNC with NIV. Austin 2010.

Prednisone 40 mg PO daily for five days for a significant exacerbation.

• Journal Club — REDUCE: Five days was noninferior to fourteen days in 314 patients, most hospitalized, with less steroid exposure. REDUCE 2013.

Oral therapy is preferred when feasible; an equivalent IV regimen is an alternative when oral treatment is impractical. Admission alone does not require IV steroids. ERS/ATS 2017.

A selective adjunct, not a routine COPD treatment step.

Journal Club — COPD Magnesium Review: Small trials suggest fewer admissions, but evidence is low-certainty; reduced ventilatory support or mortality is not established. Cochrane 2022.

Acute respiratory acidosis: pH ≤7.35, elevated PaCO₂, and persistent respiratory distress despite initial treatment. This is the strongest evidence-supported indication.

Compensated hypercapnia without acidosis does not routinely require acute NIV.

pH <7.25 increases failure risk—not an automatic intubation threshold. Close monitoring and immediate airway capability are essential.

Assess mask tolerance, aspiration risk, and secretion clearance.

Selected patients with hypercapnic drowsiness may improve with NIV; inability to protect the airway or immediate deterioration requires a different plan. ERS/ATS 2017.

• Journal Club — COPD NIV Review: NIV reduced mortality and intubation in 17 trials involving 1,264 patients; pooled numbers needed to treat were approximately 12 for mortality and 5 for intubation. Cochrane 2017.

NIV remains preferred for acute acidotic hypercapnic respiratory failure.

ATS 2026 conditionally supports HFNC in selected patients with less severe hypercapnia and mild acidemia, such as pH >7.25, only with close monitoring and prompt NIV escalation available. ATS 2026.

Journal Club — Tan 2024: In a 225-patient trial, treatment failure occurred in 25.7% with HFNC versus 14.3% with NIV. Failure included switching devices; intubation was also more frequent with HFNC. Tan 2024.

Arrest, airway-protection failure, immediate deterioration, or respiratory failure despite an appropriate NIV trial.

No single PaCO₂ or pH mandates intubation. Follow the clinical course. BTS/ICS 2016.

See RSI. Support perfusion according to cause; no automatic prophylactic fluid bolus. PREPARE II 2022.

Allow expiration rather than forcing normal CO₂. Follow expiratory flow, blood gases, BP, plateau pressure, and auto-PEEP.

Auto-PEEP is trapped end-expiratory pressure—not the external PEEP setting. Elevated plateau pressure alone does not define hyperinflation. AARC 2024.

Usual plateau-pressure goal: <30 cm H₂O. Persistent air trapping → lower minute ventilation / lengthen expiration; reassess external PEEP. Mein / Ferrera 2025.

Permissive hypercapnia may be necessary; follow baseline CO₂, pH, and hemodynamics. BTS/ICS describes pH 7.20–7.25 when needed to limit pressures in severe obstruction—not a universal safe threshold. BTS/ICS 2016.

Air trapping: Brief ventilator disconnection to permit exhalation; reduce excessive minute ventilation.

Other causes: Check tube / circuit obstruction, displacement, and tension pneumothorax.

Continue analgesia / sedation; assess synchrony and hemodynamics. AARC 2024 · Mein / Ferrera 2025.

Sustained improvement in dyspnea / effort; oxygen requirement near baseline.

No ongoing respiratory acidosis or frequent rescue-treatment requirement.

Medication access, adequate home support, inhaler technique, return precautions, and follow-up addressed. ERS/ATS 2017 — Care Setting.

Review long-acting bronchodilation, usually LABA / LAMA when indicated. ICS is selective—not automatic as in asthma; consider exacerbation history, eosinophils, and coexisting asthma. ATS 2020.

Persistent distress, oxygen above baseline, or frequent treatments despite initial care.

Important comorbidity / alternative diagnosis or an unsafe home plan. ERS/ATS 2017.

Invasive ventilation, worsening acidosis / consciousness, refractory hypoxemia, or hemodynamic instability.

High-risk NIV requires close monitoring and immediate intubation capability; location depends on local staffing and resources. BTS/ICS 2016.

Assess speech, effort, air movement, consciousness, SpO₂, pulse, and BP. Start inhaled bronchodilators; oxygen for hypoxemia.

Match the pathway to the most concerning findings. Prior intubation / ICU admission and rapid deterioration lower the escalation threshold. See Severity.

Exhaustion, weakening / paradoxical respirations, altered consciousness, minimal airflow, or refractory hypoxemia; bradycardia / hypotension are late findings.

Intubate for apnea, deteriorating consciousness, or failing ventilation. Do not delay for BiPAP. Continue medical treatment during preparation. See Intubation / Ventilation.

Few words, marked accessory muscle use, poor air entry, tachypnea, or hypoxemia.

Repeated / continuous albuterol + ipratropium + systemic steroids. Consider IV magnesium.

Alert, cooperative, protecting the airway, and stable → monitored BiPAP trial. Deterioration → intubation. See Escalation.

Phrase-length speech, accessory muscle use, wheezing, and reduced air entry.

Repeated albuterol + ipratropium when indicated + oral steroids. Escalate for persistent marked effort or deterioration.

Full sentences, preserved airflow, and minimal effort.

Inhaled albuterol and reassessment; systemic steroids for incomplete response or higher-risk features. See Treatment By Severity.

Recheck effort, speech, airflow, consciousness, oxygen requirement, and duration of relief.

Poor response / atypical findings → reconsider anaphylaxis, upper-airway obstruction, pneumothorax, pneumonia, pulmonary edema, or PE.

Discharge: Sustained improvement and a safe home plan.

Monitored Admission: Persistent symptoms / oxygen / frequent treatments.

ICU Admission: Failing ventilation or advanced respiratory support.

See Disposition.

Comfortable at rest, full sentences, little accessory muscle use, and preserved air entry.

Mild expiratory wheeze may be present; room-air SpO₂ usually ≥94%.

Breathless speech in phrases; prefers sitting upright.

Accessory muscle use, expiratory wheeze, and decreased air entry, without exhaustion or altered consciousness.

Only a few words / unable to speak normally; cannot lie comfortably.

Marked retractions / accessory muscle use, poor air movement, tachypnea, and tachycardia.

SpO₂ <92% on room air, respiratory rate >30/min, or a quiet chest indicates substantial concern. GINA 2026 — Severity Features.

Exhaustion, weakening effort, paradoxical breathing, drowsiness / confusion, or apnea.

Minimal airflow / silent chest, persistent hypoxemia despite support, or worsening hypercapnic acidosis.

Bradycardia / hypotension are late findings. Less wheezing with declining airflow is deterioration—not improvement. NHLBI — Severity / Respiratory Failure.

Useful for documenting obstruction and response in a cooperative patient; effort-dependent and less useful during extreme distress.

Routine peak-flow testing has not demonstrated improved ED outcomes or reliable admission prediction. ACEP supports selective use—not a requirement for every patient. ACEP — Peak Flow.

• GINA retains PEF as an adjunct: >70% of personal best / predicted supports a mild presentation; 50–70% moderate; <50% severe. These are supporting ranges, not standalone treatment or discharge rules. GINA 2026.

Do not delay treatment or attempt forced maneuvers in a patient with impending respiratory failure.

CXR: Focal findings, suspected complication / alternative diagnosis, or unexplained poor response—not routine.

Blood Gas: Severe distress, fatigue, or suspected ventilatory failure. Normal or rising arterial CO₂ despite severe tachypnea suggests inadequate ventilation; interpret with effort and consciousness. French Guideline 2019 — Testing.

Potassium / Lactate: Consider during prolonged high-dose β₂-agonist treatment or unexplained persistent tachypnea. Albuterol may lower potassium and raise lactate; exclude hypoperfusion and other causes. NHLBI — Laboratory Assessment · Lewis 2014.

A substitute when prior tolerance or the institutional formulary favors it; not a routine addition after albuterol.

Dose: 1.25–2.5 mg nebulized every 20 minutes for up to three doses is an adult acute-treatment option. NHLBI — Levalbuterol.

Journal Club — Levalbuterol Review: No consistent efficacy or safety advantage over albuterol. Seven trials involving 1,625 participants found no significant overall benefit; do not assume switching will eliminate β₂-agonist adverse effects. Jat 2013.

With albuterol for moderate–severe attacks or incomplete initial response; greatest value during initial ED treatment.

Dose: 0.5 mg nebulized every 20 minutes for three doses.

Not a replacement for albuterol or a necessary treatment for every mild attack. NHLBI — Ipratropium.

Early treatment for moderate–severe attacks or incomplete bronchodilator response. A rapidly resolving mild episode may not require systemic steroids.

Prednisone / prednisolone 40–50 mg PO daily for 5–7 days. A short course usually needs no taper unless other steroid exposure requires one. GINA 2026.

Oral therapy is preferred when feasible. If oral treatment is impossible, IV methylprednisolone is an alternative; routine high-dose regimens offer no established advantage. Not 125 mg every six hours. NHLBI — Steroids.

Magnesium sulfate 2 g IV over 20 minutes for severe obstruction or inadequate response to initial bronchodilators / steroids.

Monitor BP during infusion; not routine for mild attacks.

Journal Club — IV Magnesium / 3Mg: A Cochrane review found fewer admissions after inadequate first-line response; the large 3Mg trial alone did not establish a significant admission benefit. Kew 2014 · 3Mg 2013.

Consider for persistent marked work of breathing in an alert, cooperative patient who protects the airway and remains hemodynamically stable.

Continue bronchodilators; monitor closely with immediate intubation capability. Vomiting, inability to protect the airway, or worsening consciousness argues against a trial.

An example starting point is IPAP 10 / EPAP 5 cm H₂O, adjusted to effort, synchrony, and tolerance—not a fixed asthma protocol.

Worsening exhaustion, consciousness, or gas exchange → intubation. Do not prolong an unsuccessful trial.

Journal Club — Asthma NIV Review 2025: Evidence remains low-certainty: randomized trials in the 2025 review showed an imprecise effect on intubation, RR 0.46; 95% CI 0.16–1.29. NIV Review 2025.

Associated anaphylaxis: IM epinephrine immediately; follow the Anaphylaxis Pathway.

Isolated asthma: Epinephrine is not routine. Some prehospital / rescue protocols include IM epinephrine for life-threatening attacks, but additional benefit over inhaled β₂-agonists remains uncertain. No routine IV-bolus sequence; medication trials must not delay ventilation. Baggott 2022.

IV Epinephrine — Rescue Option

• Refractory life-threatening bronchospasm: Consider a titrated IV epinephrine infusion with experienced ED / critical-care oversight; not routine exacerbation treatment. Agency for Clinical Innovation
• Monitoring: Infusion pump, dedicated line, continuous ECG, and frequent BP; titrate to response and adverse effects. Queensland Ambulance Service
• Journal Club: Additional benefit remains uncertain; tachyarrhythmia and ischemic complications are concerns. PubMed
• Failing ventilation: Do not delay necessary intubation for an epinephrine trial. NHLBI, NIH

Terbutaline / IV β₂-agonists: Not routine escalation when effective inhaled treatment is available; reserve exceptional rescue decisions for experienced critical-care teams. French Guideline 2019 — β₂-Agonists.

Ketamine / Heliox: Not routine bronchodilator steps. Ketamine may be selected for induction / sedation, but evidence for a separate bronchodilator infusion is limited. See RSI. French Guideline 2019.

Antibiotics: Only for suspected bacterial infection—not the exacerbation itself. GINA 2026.

Respiratory arrest, deteriorating consciousness, exhaustion with failing ventilation, or refractory respiratory failure despite treatment.

Do not wait for a particular CO₂ or peak-flow threshold. See RSI. French Guideline 2019 — Intubation.

Allow expiration; do not chase normal CO₂. Watch the expiratory flow waveform for return toward baseline before the next breath.

Follow plateau pressure; usual goal <30 cm H₂O. High peak pressure with a lower plateau may reflect airway resistance rather than alveolar overdistension.

Air trapping / rising plateau pressure → lower minute ventilation, usually by reducing respiratory rate; shorten inspiratory time and reassess PEEP. Mein / Ferrera 2025.

Accept hypercapnia when tolerated while following pH and hemodynamics; intracranial hypertension requires particular caution.

Adequate analgesia / sedation is essential; paralysis is selective for severe dyssynchrony. French Guideline 2019.

Air trapping: Brief ventilator disconnection to permit exhalation; reassess rate, tidal volume, and expiratory time.

Tube / Circuit: Check obstruction, kinking, displacement, and equipment.

Tension pneumothorax: Evaluate immediately and decompress when indicated—not automatic bilateral chest tubes. AHA 2025 — Asthma.

See Trauma — Blunt Chest for decompression.

Sustained improvement, minimal respiratory effort, adequate room-air oxygenation, and no frequent rescue requirement.

Medication access, adequate home support, and reliable follow-up. Peak flow may support the decision; no single reading establishes safe discharge. ACEP — Peak Flow.

ICS-containing treatment—not albuterol alone.

• ICS-formoterol maintenance-and-reliever therapy (MART / SMART) when appropriate and available.

• Otherwise, an appropriate ICS-containing controller plus reliever. Not every ICS / LABA combination can serve as a reliever. NAEPP 2020 — SMART.

Complete systemic steroids when indicated. Review inhaler / spacer technique, action plan, and return precautions; follow-up within 2–7 days. GINA 2026 — Discharge.

Persistent symptoms, oxygen need, or frequent bronchodilator requirement despite treatment.

High-risk history, poor treatment response, or inadequate home support lowers the threshold. NHLBI — Disposition.

Progressive exhaustion / altered consciousness, worsening respiratory acidosis, refractory hypoxemia, or invasive ventilation.

Severe attacks requiring NIV or intensive continuous treatment need continuous reassessment and immediate intubation capability; location depends on local staffing and resources. NIV Review 2025 · AHA 2025 — Life-Threatening Asthma.

Assess respiratory effort, speech, SpO₂, consciousness, BP, and perfusion.

ECG + lung / cardiac POCUS during resuscitation. Look for ACS, arrhythmia, or acute valve disease. See Assessment / Diagnosis.

Exhaustion, deteriorating consciousness, or persistent respiratory failure despite support.

Intubation when necessary; do not prolong failing NIV. See Respiratory Support.

Hypoperfusion: Cool extremities, confusion, oliguria, or rising lactate; hypotension may be absent.

Hypotensive shock: Norepinephrine + urgent cardiology / shock-team involvement. Treat the cause; selected inotropic / mechanical support. See Shock.

Abrupt severe dyspnea, marked hypertension, diaphoresis, crackles, and hypoxemia.

CPAP / BiPAP + rapidly titrated nitroglycerin. IV loop diuretic when volume overloaded. See Nitrates.

Orthopnea, elevated JVP, edema, or weight gain without shock.

IV loop diuretic; respiratory support as needed. Nitrates selectively when BP permits. See Diuresis.

Discharge: Sustained improvement, stable oxygenation / perfusion, and reliable follow-up.

Monitored Admission: Persistent congestion, oxygen requirement, or ongoing IV treatment.

ICU Admission: Shock, invasive ventilation, or persistent severe respiratory failure.

See Disposition.

Orthopnea, paroxysmal nocturnal dyspnea, elevated JVP, crackles, edema, and recent weight gain support congestion.

Prior HF / coronary or valve disease increases suspicion. Wheezing may accompany pulmonary edema; it does not establish asthma / COPD.

No single finding establishes acute HF. Consider pneumonia, COPD / asthma, PE, pneumothorax, and noncardiogenic edema. ESC 2021 — Acute HF.

Marked accessory muscle use, inability to speak comfortably, hypoxemia, and exhaustion indicate respiratory severity.

Cool / mottled extremities, confusion, oliguria, or rising lactate suggest hypoperfusion. A preserved BP does not exclude cardiogenic shock. ACC 2025.

Hypertensive pulmonary edema: Rapidly increased filling pressures / afterload may redistribute fluid into the lungs without substantial weight gain or peripheral edema.

Volume overload: Progressive congestion favors prompt diuresis.

These patterns overlap; pulmonary edema is not automatically total-body fluid excess. ESC 2021 — Clinical Presentations.

ACS, unstable arrhythmia, hypertensive emergency, acute valve / mechanical disease, infection, or missed medications.

Ischemia, unstable rhythm, or a new concerning murmur: Urgent cause-specific evaluation / treatment—not pulmonary-edema treatment alone. AHA/ACC/HFSA 2022 — Precipitants.

Diffuse bilateral B-lines support pulmonary congestion; assess pleural effusions and alternative lung findings.

Assess LV / RV function, major valve abnormalities, and pericardial effusion. Obtain formal echocardiography when needed.

Preserved EF does not exclude acute HF. B-lines are not specific: ARDS, interstitial disease, and pneumonia can produce them. Integrate lung and cardiac findings with the examination. EACVI 2023.

• Journal Club — Pivetta 2019: Pivetta’s 518-patient randomized diagnostic study supported adding lung ultrasound to clinical assessment; it did not validate B-lines as a standalone diagnosis. Pivetta 2019.

ECG: Ischemia, infarction, and arrhythmia.

CXR: Edema, effusions, cardiomegaly, and alternative diagnoses.

• No radiographic congestion does not exclude acute HF.

  • Journal Club — ADHERE: In ADHERE, 18.7% of admitted acute-HF patients lacked congestion on the initial CXR. Collins 2006.

• Persistent suspicion requires integration with the examination and lung / cardiac POCUS—not exclusion based on the film alone. EACVI 2023.

Creatinine / Electrolytes / Troponin: Assess treatment risk and precipitants. Elevated troponin may reflect myocardial injury without ACS; interpret with symptoms, ECG, and serial change.

Blood gas for respiratory failure; lactate for suspected hypoperfusion. Do not delay stabilization for testing. ESC 2021 — Diagnostic Workup.

Useful when the diagnosis remains uncertain.

BNP <100 pg/mL or NT-proBNP <300 pg/mL: Acute HF is less likely—not impossible.

Obesity and flash pulmonary edema may produce unexpectedly low values; renal dysfunction, AF, and other illnesses may elevate them.

An elevated peptide alone does not diagnose acute HF. ESC 2021 — Natriuretic Peptides.

Supplemental oxygen for hypoxemia, generally SpO₂ <90%; avoid routine oxygen when not hypoxemic. ESC 2021.

Early CPAP or bilevel NIV for cardiogenic pulmonary edema with respiratory failure, while treating BP and congestion.

Reassess effort, consciousness, oxygenation, and BP. Positive pressure may worsen hypotension; profound shock requires individualized airway / circulatory support.

Intubation: Failing oxygenation / ventilation, exhaustion, airway-protection failure, or deterioration despite NIV. See RSI.

ERS/ATS strongly recommends CPAP or bilevel NIV; neither has established overall superiority. Pooled evidence supports fewer intubations and lower hospital mortality, despite the neutral mortality result in 3CPO. Cardiogenic-shock patients were generally excluded. ERS/ATS 2017 — Cardiogenic Pulmonary Edema.

Hypertensive pulmonary edema: Rapid vasodilation alongside NIV. Not a universal first drug for every HF presentation.

SL nitroglycerin 0.4 mg may bridge to IV treatment when BP permits.

IV infusion: 10 mcg/min initially, rapidly titrated to respiratory distress and BP; severe hypertensive presentations may need a higher-dose strategy from the outset. ACEP 2022.

Avoid with hypotension or recent PDE-5 inhibitor exposure. Preload-dependent states, including RV infarction, and severe aortic stenosis require particular caution. ESC 2021 — Vasodilators.

Topical nitroglycerin is not a required intermediate step before IV treatment.

Significant fluid overload: Prompt IV loop diuretic; do not wait for a nitrate stage. AHA/ACC/HFSA 2022 — Decongestion.

Loop-naive: Furosemide 20–40 mg IV is a usual initial dose.

Already taking a loop diuretic: Base the initial IV dose on the total daily oral furosemide-equivalent dose, renal function, and congestion. Avoid underdosing a patient already receiving substantial maintenance therapy. ESC 2021 — Diuretics.

Reassess urine output, symptoms, BP, creatinine, and electrolytes. Inadequate response requires dose escalation / reassessment rather than repeated ineffective doses.

Flash edema without substantial volume overload: Do not rely on diuresis for immediate respiratory relief. ESC 2021 — Diuretics.

Journal Club — DOSE: In 308 patients, continuous infusion did not outperform intermittent boluses on primary outcomes. Higher doses produced more diuresis but more transient renal-function worsening. DOSE 2011.

Early cardiology / shock-team involvement. Identify ACS, acute mechanical / valve disease, or arrhythmia; arrange definitive treatment.

Norepinephrine: Reasonable initial vasopressor for hypotensive cardiogenic shock.

Dobutamine / Other Inotropic Support: Selected patients with inadequate cardiac output; support BP and monitor for arrhythmia.

Persistent hypoperfusion despite medical support: Assess for temporary mechanical circulatory support / transfer. No automatic dopamine → IABP ladder. ACC 2025 — Cardiogenic Shock.

Journal Club — SOAP II: More arrhythmias with dopamine than norepinephrine: 24.1% vs 12.4%. The cardiogenic-shock mortality signal came from a subgroup—not the overall trial. De Backer 2010.

Morphine: Not routine pulmonary-edema therapy; selected analgesic / palliative indications are separate. ESC 2021.

Beta-Blockers: No initiation / escalation during shock or hemodynamic instability. Do not automatically stop established therapy in a stable, perfusing patient.

Long-Term HF Treatment: Continue established therapy when tolerated; address contraindications and optimize after stabilization. ACE inhibitors / ARNI are not a mandatory second resuscitation step. AHA/ACC/HFSA 2022 — Existing Therapy.

Selected patients with sustained improvement, stable oxygenation / perfusion, and no unresolved dangerous precipitant.

Oral regimen, medication access, home support, and reliable early follow-up established.

Risk tools support assessment; they do not independently determine discharge. ACEP 2022 — Disposition.

Review diuretic instructions, weight / symptom monitoring, return precautions, and renal / electrolyte follow-up. Arrange early HF reassessment. AHA/ACC/HFSA 2022 — Transitional Care.

Journal Club — COACH: Structured risk assessment plus rapid follow-up improved outcomes. Early discharge included up to three hospital days—not just immediate ED discharge. COACH 2023.

Persistent congestion / oxygen requirement or ongoing IV-treatment needs.

Important renal / electrolyte abnormalities, an unresolved precipitant, or an unsafe outpatient plan. AHA/ACC/HFSA 2022.

Cardiogenic shock, invasive ventilation, persistent severe respiratory failure, or intensive vasoactive support.

Ongoing NIV / rapidly titrated infusions require a setting with close monitoring and immediate escalation capability. ACC 2025 · ERS/ATS 2017.

• Journal Club — CAPE COD / REMAP-CAP: CAPE COD demonstrated a mortality benefit in selected ICU patients; the later REMAP-CAP fixed seven-day regimen did not demonstrate a large survival benefit. Patient selection and regimen remain important. CAPE COD 2023 · REMAP-CAP 2025.

Unstable / shock / severe respiratory compromise → resuscitation + urgent evaluation

Stable → probability-based diagnostic pathway

History / examination + Wells or clinical gestalt → low / intermediate / high probability

Clinical probability: Low <15% / intermediate 15–50% / high >50%

PERC negative → no further PE testing

PERC positive → D-dimer branch, not automatic CT

High-sensitivity D-dimer with YEARS or a validated age-adjusted strategy

Below the applicable cutoff → PE excluded

At or above the applicable cutoff → diagnostic imaging

CT pulmonary angiography

No D-dimer rule-out step

Reference: 2026 Multisociety PE Guideline — Figure 1.

Low: <2

Intermediate: 2–6

High: >6

Clinical judgment: “PE more likely than an alternative” requires comparing plausible diagnoses—not simply noting that PE is possible

Revised Geneva: Validated alternative; use one scoring system consistently

Reference: 2026 Multisociety Guideline — Table 3.

Low clinical probability + PERC positive

Intermediate clinical probability → D-dimer directly; no PERC exclusion step

Reference: Randomized Trial — PERC / YEARS / Age-Adjusted D-Dimer Strategy.

Below the applicable validated cutoff → PE excluded; no PE imaging

At or above the cutoff → diagnostic imaging, generally CT pulmonary angiography

Positive D-dimer ≠ PE: Requires diagnostic confirmation

Threshold selection: YEARS or a validated age-adjusted strategy; follow the complete pathway rather than selecting a different cutoff after seeing the result

Reference: 2026 Multisociety Guideline — Clinical Assessment.

Three YEARS findings:

• Clinical signs of DVT

• Hemoptysis

• PE the most likely diagnosis

Standard YEARS thresholds:

• No YEARS findings + D-dimer <1,000 ng/mL FEU → PE excluded

• ≥1 YEARS finding + D-dimer <500 ng/mL FEU → PE excluded

• At or above the applicable threshold → imaging

Assay / units: Confirm the laboratory’s reporting units before applying these thresholds

Journal Club: Original YEARS Study. Three-month symptomatic VTE after exclusion by the overall strategy: 0.61%. CTPA avoided in 48%, compared with an estimated 34% using Wells + a fixed D-dimer cutoff; not a randomized comparison.

Age-adjusted D-dimer: Use your institution’s validated age-adjusted cutoff based on its assay and reporting units

An alternative to standard YEARS; combined YEARS / age-adjusted protocols also have trial support—use a validated protocol rather than an improvised combination

Journal Club: ADJUST-PE. Among patients above the conventional cutoff but below the age-adjusted cutoff, three-month VTE occurred in 1/331—0.3% [95% CI, 0.1–1.7%]

Journal Club — Combined PE Diagnostic Strategy: Combined-strategy evidence: PERC / YEARS / Age-Adjusted D-Dimer Randomized Trial. Included low-probability/PERC-positive and intermediate-probability patients.

A / B → anticoagulate and determine whether the patient can safely go home

C → anticoagulate + admit + PERT; RV strain / troponin alone does not mean automatic thrombolysis

D → the patient is beginning to fail → support RV / perfusion and actively consider reperfusion

E → the patient has cardiopulmonary failure → resuscitate and move immediately toward advanced reperfusion / rescue

Watch the trajectory: A patient with a normal systolic BP can still be in shock and belong in Category D

Reference: 2026 AHA/ACC Multisociety PE Guideline.