🫁 ACUTE BREATHLESSNESS – INDIA

COMPREHENSIVE DUAL-LEVEL CARE PROTOCOL

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PRIMARY CARE → SECONDARY CARE

📋 For Doctors Only | Not for Public Use

Covers: Acute Severe Asthma | COPD Exacerbation | Acute Pulmonary Edema | Pulmonary Embolism

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🔰 SYMBOL LEGEND

Symbol	Meaning
✅	Common / Characteristic / Present
❌	Absent / Not seen / Rare
⚠️	Variable / Sometimes present / May occur

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🏥 LEVEL OF CARE OVERVIEW

Procedure/Action	Primary Care	Secondary/Tertiary Care
Clinical recognition & differentiation	✅	✅
Oxygen therapy	✅	✅
Nebulization (Salbutamol, Ipratropium)	✅	✅
IV Corticosteroids	✅	✅
IV Diuretics (Furosemide)	✅	✅
IV Aminophylline	⚠️ (if experienced)	✅
NIV (BiPAP/CPAP)	❌	✅
IV MgSO₄ (Asthma)	⚠️	✅
Anticoagulation (PE)	⚠️ (if confident)	✅
Thrombolysis (Massive PE)	❌	✅
Intubation / Mechanical ventilation	❌	✅
CTPA / Echocardiography	❌	✅
ICU-level care	❌	✅

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⏱️ CRITICAL TIME TARGETS

Milestone	Target Time
Assess airway, breathing, circulation	Immediate
Oxygen therapy (if SpO₂ low)	Immediate
First nebulization	≤ 5 min
IV access	≤ 10 min
Determine likely cause	≤ 15 min
Specific treatment initiated	≤ 15-30 min
Reassess response	Every 15-30 min
Decision to escalate / transfer	≤ 1 hour if not improving

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📖 OVERVIEW: CAUSES OF ACUTE BREATHLESSNESS

Common Causes (Focus of This Protocol)

Quick Comparison Table

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Clinical Differentiation at Bedside

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🟢 PART 1 — PRIMARY CARE

Goal: Recognise → Stabilise → Differentiate → Treat → Transfer if needed

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1️⃣ INITIAL ASSESSMENT (FIRST 5 MINUTES)

Rapid Assessment

Check	Action
Airway	Patent? Stridor?
Breathing	RR, SpO₂, accessory muscle use, ability to speak
Circulation	HR, BP, peripheries, JVP
Disability	GCS, confusion (hypoxia/hypercapnia)

Severity Assessment – General

Sign	Moderate	Severe	Life-Threatening
Talks in	Sentences	Phrases	Words / Unable
RR	20-25/min	25-30/min	> 30/min or exhaustion
SpO₂ (room air)	92-95%	88-92%	< 88%
HR	100-120	> 120	Bradycardia (ominous)
Accessory muscles	⚠️	✅	✅
Mental status	Alert	Agitated	Confused / Drowsy
Cyanosis	❌	⚠️	✅

Immediate Actions

Step	Action
1	Position – Sit upright (unless hypotensive)
2	Oxygen – Maintain SpO₂ 92-96% (88-92% if COPD)
3	IV access
4	ECG – If available
5	Blood glucose – Rule out metabolic cause
6	Focused history – Cardiac, respiratory, risk factors

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2️⃣ OXYGEN THERAPY

Oxygen Delivery Devices

Device	Flow Rate	FiO₂ Delivered	When to Use
Nasal cannula	1-6 L/min	24-44%	Mild hypoxia
Simple face mask	5-10 L/min	40-60%	Moderate hypoxia
Venturi mask	2-15 L/min	24-60% (fixed)	COPD (controlled O₂)
Non-rebreather mask	10-15 L/min	80-90%	Severe hypoxia

Oxygen Targets

Patient	Target SpO₂
Most patients	94-98%
COPD / Chronic hypercapnia risk	88-92%
Acute severe illness (non-COPD)	≥ 94%

⚠️ In COPD: High-flow oxygen can suppress respiratory drive → Use controlled oxygen (Venturi mask)

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3️⃣ ACUTE SEVERE ASTHMA – PRIMARY CARE MANAGEMENT

Definition

Category	Features
Moderate Exacerbation	Increasing symptoms, PEF 50-75% predicted, no severe features
Acute Severe Asthma	PEF 33-50% predicted OR any of: RR ≥ 25, HR ≥ 110, unable to complete sentences
Life-Threatening Asthma	PEF < 33%, SpO₂ < 92%, silent chest, cyanosis, bradycardia, confusion, exhaustion, hypotension
Near-Fatal Asthma	Raised PaCO₂, requiring intubation

Severity Assessment – Asthma-Specific

Feature	Moderate	Severe	Life-Threatening
Talks in	Sentences	Phrases	Words / Unable
PEF	50-75%	33-50%	< 33%
SpO₂	> 94%	90-94%	< 92%
RR	< 25	≥ 25	> 30 or exhaustion
HR	< 110	≥ 110	Bradycardia
Accessory muscles	❌	✅	✅
Wheeze	Moderate	Loud	Silent chest ⚠️
Mental status	Normal	Agitated	Confused / Drowsy

📌 Silent chest = No air movement = Life-threatening – do NOT be falsely reassured

Immediate Treatment Protocol

Step	Drug	Dose	Route	Frequency
1	Oxygen	Titrate	Mask/Cannula	SpO₂ 94-98%
2	Salbutamol	2.5-5 mg	Nebulized	q20min × 3, then q1-4h
3	Ipratropium bromide	500 mcg	Nebulized	q20min × 3 (add to salbutamol)
4	Hydrocortisone	100 mg	IV	Stat, then q6h
	OR Prednisolone	40-50 mg	PO	Once daily
5	Magnesium Sulfate (if severe)	2 g	IV over 20 min	Single dose

Nebulization Protocol

Severity	Salbutamol	Ipratropium
Moderate	2.5 mg q4-6h	Add for initial doses
Severe	5 mg q20min × 3, then q1-2h	500 mcg q20min × 3
Life-threatening	Continuous 5-10 mg/hr	500 mcg q20min × 3

Nebulizer Preparation

Drug	Available As	How to Give
Salbutamol (Asthalin)	2.5 mg/2.5 mL or 5 mg/2.5 mL respules	Nebulize with O₂ at 6-8 L/min
Ipratropium (Duolin)	Combined with Salbutamol OR 500 mcg/2 mL	Mix in nebulizer

Magnesium Sulfate

Indication	Severe/Life-threatening asthma not responding to initial bronchodilators
Dose	2 g (4 mL of 50% MgSO₄)
Dilution	In 100 mL NS
Infusion	Over 20 minutes
Caution	Monitor BP; may cause flushing, hypotension

Response Assessment (After 15-30 min)

Response	Features	Action
Good response	SpO₂ > 94%, talks in sentences, RR < 25, PEF > 50%	Continue treatment; may observe
Incomplete response	Some improvement but still symptomatic	Continue aggressive treatment; prepare transfer
Poor/No response	No improvement or worsening	URGENT TRANSFER

Transfer Indications in Asthma

Indication
Life-threatening features at any time
Severe features not responding after 1 hour
Previous near-fatal asthma
SpO₂ < 92% despite treatment
PEF < 50% after treatment
Patient exhaustion
Silent chest
Altered consciousness
Pregnancy with severe asthma

What NOT to Do in Acute Asthma

⛔ Avoid
Sedatives (respiratory depression)
Mucolytics (may worsen bronchospasm)
Chest physiotherapy during acute attack
High-flow O₂ without monitoring in COPD overlap
Delaying steroids

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4️⃣ COPD EXACERBATION – PRIMARY CARE MANAGEMENT

Definition

Acute worsening of respiratory symptoms beyond normal day-to-day variation requiring change in therapy

Cardinal Symptoms of COPD Exacerbation

Symptom
Increased dyspnea
Increased sputum volume
Increased sputum purulence

Severity Assessment – COPD Exacerbation

Severity	Features
Mild	Increased dyspnea; managed with short-acting bronchodilators
Moderate	Requires steroids ± antibiotics
Severe	Requires hospitalization; respiratory failure

Indications for Hospital/Transfer

Indication
Severe symptoms (at rest, accessory muscle use)
Acute respiratory failure
New cyanosis
Failure to respond to initial treatment
Peripheral edema (new or worsening)
Altered mental status
Inability to care for self at home
Uncertain diagnosis
Serious comorbidities (heart failure, arrhythmias)
Frequent exacerbations
Older age
Insufficient home support

Immediate Treatment Protocol

Step	Drug	Dose	Route	Frequency
1	Controlled Oxygen	Venturi 24-28%	Mask	Target SpO₂ 88-92%
2	Salbutamol	2.5-5 mg	Nebulized	q20min × 3, then q4-6h
3	Ipratropium bromide	500 mcg	Nebulized	q4-6h
4	Hydrocortisone	100 mg	IV	Stat
	OR Prednisolone	40 mg	PO	Once daily × 5 days
5	Antibiotics (if indicated)	See below	PO/IV	5-7 days

When to Give Antibiotics in COPD Exacerbation

Give Antibiotics If
Increased sputum purulence (green/yellow)
Increased sputum volume + increased dyspnea
Requires mechanical ventilation
Severe exacerbation

Antibiotic Selection for COPD Exacerbation (India)

Severity	First-Line	Alternative
Mild-Moderate (Outpatient)	Amoxicillin 500 mg TID × 5-7 days	Doxycycline 100 mg BD × 5-7 days
	OR Azithromycin 500 mg OD × 3-5 days
Moderate (Hospitalized)	Amoxicillin-Clavulanate 625 mg TID	Levofloxacin 750 mg OD × 5 days
Severe / ICU / Pseudomonas risk	Piperacillin-Tazobactam 4.5g IV TID	Cefoperazone-Sulbactam 2g IV BD
	Add Azithromycin 500 mg OD

Risk Factors for Pseudomonas in COPD

Risk Factor
Recent hospitalization (≥ 2 days in past 90 days)
Frequent antibiotics (≥ 4 courses in past year)
Severe COPD (FEV1 < 50%)
Prior Pseudomonas isolation
Bronchiectasis
Chronic oral corticosteroids

Controlled Oxygen in COPD

Principle	Details
Target SpO₂	88-92%
Device	Venturi mask (delivers fixed FiO₂)
Start with	24% or 28% Venturi
Rationale	Chronic CO₂ retainers may lose hypercapnic drive
Monitor	ABG if available; watch for drowsiness

Venturi Mask Settings

Color	FiO₂	O₂ Flow Rate
Blue	24%	2-4 L/min
White	28%	4-6 L/min
Yellow	35%	8-10 L/min
Red	40%	10-12 L/min
Green	60%	12-15 L/min

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5️⃣ ACUTE PULMONARY EDEMA – PRIMARY CARE MANAGEMENT

Definition

Rapid accumulation of fluid in pulmonary interstitium and alveoli, usually due to acute heart failure or fluid overload

Common Causes

Cause	Examples
Cardiogenic	Acute MI, decompensated HF, hypertensive crisis, arrhythmia, valvular disease
Non-Cardiogenic	ARDS, fluid overload, neurogenic, high altitude

Clinical Features

Feature	Description
Symptoms	Acute dyspnea, orthopnea, PND, pink frothy sputum
Signs	Tachypnea, tachycardia, elevated JVP, bilateral crackles, S3 gallop, peripheral edema
History	Heart disease, HTN, recent MI, missed medications

Classification by Blood Pressure

BP	Classification	Implication
SBP > 140	Hypertensive APE	Vasodilators primary therapy
SBP 90-140	Normotensive APE	Balanced approach
SBP < 90	Cardiogenic Shock	Inotropes; avoid vasodilators

Immediate Treatment Protocol ("LMNOP")

Letter	Treatment	Details
L	Lasix (Furosemide)	40-80 mg IV (1-2× home dose)
M	Morphine	2-4 mg IV (caution; may cause resp depression)
N	Nitrates	GTN SL 0.5 mg q5min or infusion
O	Oxygen	Target SpO₂ 94-98%
P	Position	Sit upright, legs dependent

Detailed Treatment Protocol

Step	Drug	Dose	Route	Notes
1	Position	Sit upright	—	Reduces venous return
2	Oxygen	High-flow	Mask	Target SpO₂ > 94%
3	Furosemide	40-80 mg	IV push	Double if on chronic diuretics
4	GTN (Nitroglycerin)	0.5 mg SL q5min × 3	SL	Only if SBP > 100 mmHg
		10-200 mcg/min	IV infusion	Titrate to BP
5	Morphine	2-4 mg	IV slow	⚠️ Use cautiously; may worsen outcome

Furosemide Dosing

Scenario	Dose
Not on chronic diuretics	40 mg IV
On oral furosemide	1-2× oral dose IV
Inadequate response	Double dose after 20-30 min
Maximum single dose	200 mg

GTN (Nitroglycerin) Options

Form	Dose	Notes
Sublingual tablet	0.5 mg q5min × 3	⛔ if SBP < 100
Sublingual spray	1-2 sprays q5min × 3	⛔ if SBP < 100
Transdermal patch	5-10 mg	For ongoing use
IV infusion	10-200 mcg/min	Titrate to BP and symptoms

GTN Infusion Preparation

Preparation	Details
50 mg GTN in 250 mL D5W	200 mcg/mL
Start	5-10 mL/hr (10-20 mcg/min)
Titrate	Increase by 5 mL/hr every 5-10 min
Target	Symptom relief, SBP > 100

📌 Morphine: Recent evidence suggests caution – may increase mortality. Use only if severe agitation/distress and GTN insufficient.

Cardiogenic Shock (SBP < 90) – Different Approach

⚠️ Different Management
⛔ Avoid GTN and Morphine
⛔ Cautious with diuretics (may worsen hypotension)
IV fluids contraindicated (already fluid overloaded)
Needs inotropes (Dobutamine) – at higher centre
TRANSFER IMMEDIATELY

Response Assessment

Response	Features	Action
Good response	Dyspnea improved, SpO₂ rising, urine output	Continue treatment
Partial response	Some improvement	Repeat diuretic; continue GTN
No response	Persistent symptoms, worsening SpO₂	TRANSFER for NIV/Inotropes

Transfer Indications

Indication
SBP < 90 mmHg (cardiogenic shock)
No improvement after initial treatment
SpO₂ < 90% despite oxygen
Need for NIV or intubation
Suspected acute MI (needs cath lab)
New arrhythmia (AF with RVR, VT)
Severe renal impairment

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6️⃣ PULMONARY EMBOLISM – PRIMARY CARE MANAGEMENT

Clinical Suspicion

PE should be suspected in any patient with sudden-onset breathlessness, especially with risk factors

Risk Factors for VTE/PE

Major Risk Factors	Minor Risk Factors
Recent surgery (especially orthopedic, pelvic)	Obesity
Major trauma	Smoking
Lower limb fracture	Long travel (> 6 hrs)
Immobilization > 3 days	Pregnancy / Postpartum
Previous VTE	Oral contraceptives / HRT
Active cancer	Varicose veins
Spinal cord injury	Age > 60
	Heart failure
	Nephrotic syndrome

Clinical Features

Feature	Description
Symptoms	Sudden dyspnea, pleuritic chest pain, hemoptysis, syncope
Signs	Tachypnea, tachycardia, hypoxia, unilateral leg swelling
Classic triad	Dyspnea + Chest pain + Hemoptysis (only 20% have all three)

Modified Wells Score for PE

Criterion	Points
Clinical signs of DVT	3
PE is most likely diagnosis	3
Heart rate > 100	1.5
Immobilization ≥ 3 days or surgery within 4 weeks	1.5
Previous PE or DVT	1.5
Hemoptysis	1
Active cancer (treatment within 6 months)	1

Score	Probability	Action
≤ 4	PE unlikely	D-dimer (at higher centre)
> 4	PE likely	CTPA (at higher centre)

Primary Care Actions if PE Suspected

Step	Action
1	Oxygen – High-flow to maintain SpO₂ > 94%
2	IV access
3	Assess hemodynamic stability
4	Do NOT delay transfer for investigations
5	If confident and PE likely: Start anticoagulation (see below)
6	TRANSFER to higher centre for CTPA

Anticoagulation at Primary Care (If PE Highly Suspected)

Drug	Dose	Notes
Enoxaparin (LMWH)	1 mg/kg SC	If confident diagnosis; pre-alert receiving hospital
OR Unfractionated Heparin	80 IU/kg IV bolus	If available

📌 If unsure, do NOT delay transfer for anticoagulation – can be started at higher centre

Massive PE – Recognition

Sign	Significance
Hypotension (SBP < 90 for > 15 min)	Massive PE
Cardiac arrest	Massive PE
Severe RV dysfunction	Submassive/Massive PE
Syncope	May indicate massive PE

Massive PE at Primary Care

Action
High-flow oxygen
IV access
IV fluids (250-500 mL bolus) – cautious
IMMEDIATE TRANSFER (needs thrombolysis/embolectomy)
If cardiac arrest: CPR; thrombolysis may be considered

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7️⃣ OTHER CAUSES – BRIEF OVERVIEW

Pneumonia with Respiratory Distress

Management
Oxygen
IV antibiotics (per sepsis/pneumonia protocol)
IV fluids
Transfer if severe

Pneumothorax

Clinical Features	Management
Sudden onset, unilateral absent breath sounds, hyperresonance	Oxygen; Needle decompression if tension (2nd ICS MCL); Transfer

Metabolic Acidosis (e.g., DKA)

Clinical Features	Management
Kussmaul breathing, fruity breath, hyperglycemia	Per DKA protocol

Anemia (Severe)

Clinical Features	Management
Dyspnea on exertion, pallor, tachycardia	Oxygen; IV fluids; Transfer for transfusion

Anxiety / Hyperventilation

Clinical Features	Management
Perioral numbness, carpopedal spasm, normal SpO₂	Reassurance; Slow breathing; Rule out organic cause first

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8️⃣ TRANSFER PROTOCOL

Transfer Urgency

Condition	Urgency
Life-threatening asthma	IMMEDIATE
Severe asthma not responding	URGENT
Severe COPD with respiratory failure	URGENT
Acute pulmonary edema not responding	URGENT
Cardiogenic shock	IMMEDIATE
Suspected massive PE	IMMEDIATE
Suspected PE (stable)	URGENT
Pneumothorax	URGENT

Pre-Transfer Checklist

Item	Done?
Oxygen running, SpO₂ monitored	☐
IV access secure	☐
Nebulizations given	☐
Steroids given	☐
Diuretics given (if pulmonary edema)	☐
Vitals documented	☐
All treatments documented with times	☐
Receiving hospital pre-alerted	☐

During Transport

Requirement	Details
Monitoring	Continuous SpO₂; BP every 5-10 min
Oxygen	Ensure adequate supply
Nebulizer	Portable nebulizer if available
Emergency drugs	Adrenaline, Salbutamol inhaler
Position	Upright if pulmonary edema/asthma; Supine if hypotensive

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🔵 PART 2 — SECONDARY/TERTIARY CARE

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9️⃣ EMERGENCY DEPARTMENT PROTOCOL

Initial Assessment

Action	Target Time
Primary survey	Immediate
SpO₂, BP, HR, RR	Immediate
IV access (if not present)	≤ 5 min
ECG	≤ 10 min
Chest X-ray	≤ 30 min
ABG	≤ 30 min
Blood tests	≤ 30 min
Determine cause	≤ 30 min
Specific treatment	Immediate

Investigations

Investigation	Purpose
SpO₂	Oxygenation
ABG	PaO₂, PaCO₂, pH, lactate
ECG	MI, arrhythmia, RV strain (PE)
Chest X-ray	Cardiomegaly, pulmonary edema, consolidation, pneumothorax
CBC	Anemia, infection
RFT	Renal function
BNP / NT-proBNP	Heart failure
Troponin	MI, PE (RV strain)
D-dimer	PE (if low clinical probability)
Procalcitonin	Infection
Echo	LV/RV function, effusion
CTPA	PE diagnosis

ABG Interpretation

Pattern	pH	PaCO₂	PaO₂	HCO₃	Suggests
Type 1 Respiratory Failure	Normal/↓	Normal/↓	↓↓	Normal	PE, Pneumonia, ARDS, Pulmonary edema
Type 2 Respiratory Failure	↓	↑↑	↓	↑ (if chronic)	COPD, Severe asthma, Neuromuscular
Metabolic Acidosis	↓↓	↓ (compensatory)	Variable	↓↓	DKA, Sepsis, Renal failure

Chest X-ray Findings

Finding	Suggests
Cardiomegaly, Kerley B lines, bat-wing infiltrates	Pulmonary edema
Hyperinflation, flat diaphragm	COPD/Asthma
Consolidation	Pneumonia
Absent lung markings, lung edge visible	Pneumothorax
Wedge-shaped opacity, oligemia	PE (rare findings)
Clear	PE, Asthma (may be normal)

ECG Findings

Finding	Suggests
ST elevation/depression, T inversion	MI
AF with RVR	Arrhythmia-induced heart failure
S1Q3T3, RV strain, RBBB	PE
Peaked T waves	Hyperkalemia
Low voltage	Pericardial effusion

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🔟 ACUTE SEVERE ASTHMA – SECONDARY CARE MANAGEMENT

Continued Treatment

Treatment	Details
Oxygen	Target SpO₂ 94-98%
Continuous nebulization	Salbutamol 5-10 mg/hr if severe
IV Corticosteroids	Hydrocortisone 100 mg q6h OR Methylprednisolone 40-60 mg IV
IV Magnesium Sulfate	2 g IV over 20 min (if not given)
Consider NIV	BiPAP if fatiguing
Consider Aminophylline	If refractory (caution: narrow therapeutic index)

Aminophylline Protocol (If Refractory)

Phase	Dose	Route	Notes
Loading (not on theophylline)	5 mg/kg	IV over 20 min	Monitor ECG
Loading (on theophylline)	⛔ Omit or give 2.5 mg/kg		Check level
Maintenance	0.5-0.7 mg/kg/hr	IV infusion	Reduce in elderly, liver disease

Aminophylline Preparation

Preparation	Details
250 mg Aminophylline in 250 mL D5W	1 mg/mL
Loading (70 kg patient)	350 mg = 350 mL over 20 min
Maintenance	35-50 mL/hr

Indications for Intubation

Indication
Respiratory arrest
Severe hypoxia despite NIV
Severe hypercapnia with acidosis (pH < 7.2)
Exhaustion, unable to maintain respiratory effort
Altered consciousness
Hemodynamic instability

Mechanical Ventilation in Asthma

Parameter	Target
Mode	Volume control
Tidal volume	6-8 mL/kg
RR	Low (10-14/min) – allow expiration
I:E ratio	1:3 or 1:4 (prolonged expiration)
PEEP	Low (3-5 cm H₂O) – beware auto-PEEP
Permissive hypercapnia	Acceptable (pH > 7.2)

📌 Asthmatic patients are difficult to ventilate – sedation, low RR, long expiratory time needed

Adjunctive Therapies (Limited Evidence)

Therapy	Details
IV Salbutamol	5 mcg/min, increase to 20 mcg/min; last resort
Ketamine	0.5-1 mg/kg IV; bronchodilator + sedative
Heliox	70:30 Helium:Oxygen; reduces airway resistance
ECMO	Refractory cases

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1️⃣1️⃣ COPD EXACERBATION – SECONDARY CARE MANAGEMENT

Continued Treatment

Treatment	Details
Controlled oxygen	Venturi 24-28%; target SpO₂ 88-92%
Nebulized bronchodilators	Salbutamol 2.5-5 mg q4-6h + Ipratropium 500 mcg q6h
Systemic steroids	Prednisolone 40 mg PO OD × 5 days OR Hydrocortisone 100 mg IV q6h
Antibiotics (if indicated)	As per severity (see earlier table)
NIV (BiPAP)	If hypercapnic respiratory failure

Indications for NIV in COPD

Indication
Respiratory acidosis (pH < 7.35, PaCO₂ > 45)
Severe dyspnea with accessory muscle use
Hypoxia not corrected with oxygen alone
Respiratory rate > 25/min

NIV Settings for COPD

Parameter	Initial Setting	Titration
Mode	BiPAP (IPAP/EPAP)	—
IPAP	10-12 cm H₂O	Increase by 2 every 10-15 min to max 20-25
EPAP	4-5 cm H₂O	May increase to 6-8 if needed
Target	RR < 25, improved pH/PaCO₂, reduced work of breathing
FiO₂	Titrate to SpO₂ 88-92%	—

NIV Failure – Consider Intubation

Sign of NIV Failure
Worsening pH after 1-2 hrs of NIV
No improvement in PaCO₂
Worsening hypoxia despite FiO₂ adjustment
Intolerance to mask
Excessive secretions
Hemodynamic instability
Altered consciousness (worsening)

Mechanical Ventilation in COPD

Parameter	Target
Mode	Volume control or Pressure support
Tidal volume	6-8 mL/kg
RR	10-14/min (avoid auto-PEEP)
I:E ratio	1:2.5 to 1:4
PEEP	Low (auto-PEEP may be present)
Target	pH > 7.25; avoid aggressive correction of hypercapnia

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1️⃣2️⃣ ACUTE PULMONARY EDEMA – SECONDARY CARE MANAGEMENT

Continued Treatment

Treatment	Details
Position	Upright
Oxygen / NIV	High-flow O₂ or CPAP/BiPAP
Diuretics	Furosemide IV; repeat if needed
Vasodilators	GTN infusion (if SBP > 100)
Treat underlying cause	MI, arrhythmia, hypertensive crisis

NIV in Pulmonary Edema

Mode	Setting	Benefit
CPAP	5-10 cm H₂O	Reduces preload, improves oxygenation
BiPAP	IPAP 10-15, EPAP 5-8	Additional ventilatory support

📌 NIV reduces intubation and mortality in acute pulmonary edema – use early

Inotropes (Cardiogenic Shock)

Drug	Dose	Indication
Dobutamine	2-20 mcg/kg/min	Low cardiac output (SBP 70-90)
Norepinephrine	0.1-1 mcg/kg/min	Severe hypotension (SBP < 70)
Dopamine	5-20 mcg/kg/min	Alternative to Dobutamine

Inotrope Preparation

Drug	Preparation	Concentration
Dobutamine	250 mg in 250 mL D5W	1000 mcg/mL
Norepinephrine	4 mg in 50 mL D5W	80 mcg/mL

Treat Underlying Cause

Cause	Treatment
Acute MI	Revascularization (PCI)
AF with RVR	Rate control (Beta-blocker, Digoxin) or Cardioversion
Hypertensive crisis	IV antihypertensives (GTN, Labetalol)
Valvular emergency	Surgery

Monitoring

Parameter	Frequency
SpO₂	Continuous
BP	Every 5-15 min
Urine output	Hourly (catheterize)
Repeat ABG	1-2 hrs after intervention
Echo	As soon as available

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1️⃣3️⃣ PULMONARY EMBOLISM – SECONDARY CARE MANAGEMENT

Risk Stratification

Category	Features	Mortality
Low Risk	No RV dysfunction, normal biomarkers	< 1%
Intermediate-Low	RV dysfunction OR elevated biomarkers	3-7%
Intermediate-High	RV dysfunction AND elevated biomarkers	7-15%
High Risk (Massive)	Hypotension or shock	> 15-25%

Anticoagulation Protocol

Phase	Options
Initial (First 5-10 days)	LMWH or Fondaparinux or UFH
Long-term (3-6 months or longer)	DOAC (preferred) or Warfarin

Anticoagulation Dosing

Drug	Dose	Notes
Enoxaparin	1 mg/kg SC BD	Or 1.5 mg/kg SC OD
Fondaparinux	5-10 mg SC OD (weight-based)	Avoid if CrCl < 30
UFH	80 IU/kg bolus → 18 IU/kg/hr	Monitor aPTT (target 1.5-2.5×)
Rivaroxaban	15 mg BD × 3 weeks → 20 mg OD	Can start immediately
Apixaban	10 mg BD × 7 days → 5 mg BD	Can start immediately

When to Use UFH (Instead of LMWH)

Indication
Massive PE (may need thrombolysis)
High bleeding risk (reversible)
Severe renal impairment (CrCl < 30)
Obesity (> 150 kg)
Planned invasive procedure

Thrombolysis for Massive PE

Indication
Massive PE with hemodynamic instability (SBP < 90 for > 15 min)
Cardiac arrest with suspected PE
⚠️ May consider in intermediate-high risk with clinical deterioration

Drug	Dose	Administration
Alteplase (tPA)	100 mg	IV over 2 hours
	OR 0.6 mg/kg (max 50 mg)	Over 15 min (accelerated)
Tenecteplase	Weight-based (same as for MI)	Single IV bolus

Contraindications to Thrombolysis

Absolute	Relative
Prior intracranial hemorrhage	SBP > 180 or DBP > 110
Ischemic stroke within 3 months	Recent surgery (within 3 weeks)
Active bleeding	Current anticoagulant use
Known brain tumor/AVM	Pregnancy
Recent brain/spine surgery	Non-compressible vascular puncture

Surgical/Interventional Options

Option	Indication
Catheter-directed therapy	Intermediate-high risk; contraindication to systemic thrombolysis
Surgical embolectomy	Massive PE with contraindication to thrombolysis; failed thrombolysis
IVC filter	Contraindication to anticoagulation; recurrent PE on anticoagulation

Monitoring

Parameter	Frequency
SpO₂, HR, BP	Continuous
Signs of bleeding	Continuous
Repeat Echo	After 24-48 hrs if RV dysfunction
aPTT (if on UFH)	Every 6 hrs until stable

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1️⃣4️⃣ VENTILATORY SUPPORT – SUMMARY

Non-Invasive Ventilation (NIV)

Indication	Mode	Settings
COPD with hypercapnic failure	BiPAP	IPAP 10-20, EPAP 4-6
Acute pulmonary edema	CPAP or BiPAP	CPAP 5-10 or BiPAP IPAP 10-15, EPAP 5-8
Asthma (fatiguing)	BiPAP	IPAP 10-15, EPAP 5

NIV Contraindications

Absolute	Relative
Cardiac or respiratory arrest	Hemodynamic instability
Unable to protect airway	Excessive secretions
Facial trauma/surgery	Agitation (uncooperative)
Uncontrolled vomiting	Recent esophageal/gastric surgery
Severe encephalopathy (GCS < 8)

Indications for Intubation

Indication
Respiratory arrest
Failure of NIV
Severe hypoxia (SpO₂ < 85% despite NIV)
Severe acidosis (pH < 7.2) worsening on NIV
Inability to protect airway (GCS < 8)
Hemodynamic instability
Severe agitation/combativeness

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1️⃣5️⃣ DISCHARGE PLANNING

Discharge Criteria

Condition	Criteria
Asthma	PEF > 75%; stable on inhaled therapy; no night wakening; able to use inhaler correctly
COPD	Stable on usual bronchodilators; able to manage at home; SpO₂ stable on room air or home O₂
Pulmonary Edema	Symptom resolution; oral diuretics tolerated; stable weight; BP controlled
PE	Anticoagulation established; hemodynamically stable; adequate outpatient follow-up

Discharge Medications

Asthma

Category	Medication
Reliever	Salbutamol MDI (as needed)
Controller	ICS (Budesonide, Fluticasone) or ICS-LABA (Budesonide-Formoterol, Fluticasone-Salmeterol)
Oral steroids	Prednisolone 40 mg OD × 5-7 days (to complete course)
Spacer	Prescribe if using MDI

COPD

Category	Medication
Bronchodilators	LAMA (Tiotropium) ± LABA (Formoterol, Salmeterol)
ICS	Add if frequent exacerbations
Oral steroids	Prednisolone 40 mg OD (complete 5-day course)
Antibiotics	Complete course if started
Home O₂	If chronic hypoxia (arrange assessment)

Heart Failure (Post-APE)

Category	Medication
Diuretics	Furosemide (oral dose adjusted)
ACE-I / ARB	Ramipril, Enalapril, Losartan
Beta-blocker	Carvedilol, Metoprolol, Bisoprolol (start low, uptitrate)
MRA	Spironolactone 25-50 mg
SGLT2-I	Dapagliflozin, Empagliflozin (if EF < 40%)
Treat cause	Statin, antiplatelets if IHD

Pulmonary Embolism

Category	Medication	Duration
Anticoagulation	Rivaroxaban 15 mg BD × 3 weeks → 20 mg OD	3-6 months (or longer)
	OR Apixaban 10 mg BD × 7 days → 5 mg BD
	OR Warfarin (target INR 2-3)
Duration	Provoked PE: 3 months
	Unprovoked PE: 6 months to indefinite
	Cancer-associated: Indefinite

Patient Education

Condition	Education Points
Asthma	Trigger avoidance, inhaler technique, recognizing worsening, action plan
COPD	Smoking cessation, inhaler technique, recognizing exacerbation, pulmonary rehab
Heart Failure	Daily weights, fluid restriction, low-salt diet, medication compliance, warning signs
PE	Anticoagulation compliance, bleeding signs, compression stockings, mobility

Follow-up

Condition	Follow-up
Asthma	GP in 1 week; Pulmonologist in 4-6 weeks
COPD	GP in 1-2 weeks; Pulmonologist for optimization
Heart Failure	Cardiology in 1-2 weeks; daily weight monitoring
PE	Hematology/Medicine in 2-4 weeks; repeat imaging if needed

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📌 QUICK REFERENCE CARDS

🔴 PRIMARY CARE – ACUTE BREATHLESSNESS CARD

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💊 NEBULIZATION QUICK REFERENCE

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💉 IV MEDICATIONS QUICK REFERENCE

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🎯 OXYGEN TARGETS

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🆚 DIFFERENTIATION TABLE

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⚠️ CRITICAL WARNINGS

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🚨 LIFE-THREATENING FEATURES

Asthma

Feature
Silent chest
Cyanosis
Poor respiratory effort / Exhaustion
Bradycardia / Hypotension
Confusion / Altered consciousness
SpO₂ < 92%
PEF < 33%

COPD

Feature
Severe acidosis (pH < 7.25)
Severe hypercapnia (PaCO₂ > 70)
Severe hypoxia (PaO₂ < 50 despite O₂)
Altered consciousness
Hemodynamic instability

Pulmonary Edema

Feature
Cardiogenic shock (SBP < 90)
SpO₂ < 90% despite O₂
Respiratory failure
Acute MI

Pulmonary Embolism

Feature
Hypotension (SBP < 90)
Cardiac arrest
Severe hypoxia
RV failure

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📚 ABBREVIATIONS

Abbreviation	Full Form
SpO₂	Oxygen saturation
PEF	Peak Expiratory Flow
ABG	Arterial Blood Gas
PaO₂	Partial pressure of oxygen
PaCO₂	Partial pressure of carbon dioxide
FiO₂	Fraction of inspired oxygen
RR	Respiratory Rate
HR	Heart Rate
BP	Blood Pressure
SBP	Systolic Blood Pressure
JVP	Jugular Venous Pressure
APE	Acute Pulmonary Edema
AHF	Acute Heart Failure
PE	Pulmonary Embolism
DVT	Deep Vein Thrombosis
VTE	Venous Thromboembolism
COPD	Chronic Obstructive Pulmonary Disease
ARDS	Acute Respiratory Distress Syndrome
NIV	Non-Invasive Ventilation
CPAP	Continuous Positive Airway Pressure
BiPAP	Bilevel Positive Airway Pressure
IPAP	Inspiratory Positive Airway Pressure
EPAP	Expiratory Positive Airway Pressure
PEEP	Positive End-Expiratory Pressure
ICS	Inhaled Corticosteroid
LABA	Long-Acting Beta-Agonist
LAMA	Long-Acting Muscarinic Antagonist
SABA	Short-Acting Beta-Agonist
SAMA	Short-Acting Muscarinic Antagonist
MDI	Metered-Dose Inhaler
GTN	Glyceryl Trinitrate (Nitroglycerin)
MgSO₄	Magnesium Sulfate
LMWH	Low Molecular Weight Heparin
UFH	Unfractionated Heparin
DOAC	Direct Oral Anticoagulant
CTPA	CT Pulmonary Angiography
RV	Right Ventricle
LV	Left Ventricle
BNP	Brain Natriuretic Peptide
NT-proBNP	N-terminal pro-BNP
ECG	Electrocardiogram
CXR	Chest X-Ray
PND	Paroxysmal Nocturnal Dyspnea
MRA	Mineralocorticoid Receptor Antagonist
SGLT2-I	Sodium-Glucose Cotransporter-2 Inhibitor
ACE-I	Angiotensin-Converting Enzyme Inhibitor
ARB	Angiotensin Receptor Blocker
IVC	Inferior Vena Cava
OD	Once Daily
BD	Twice Daily
TID	Three Times Daily
q4h	Every 4 hours
q6h	Every 6 hours
GCS	Glasgow Coma Scale
IHD	Ischemic Heart Disease
AF	Atrial Fibrillation
RVR	Rapid Ventricular Response
MI	Myocardial Infarction
PCI	Percutaneous Coronary Intervention
ECMO	Extracorporeal Membrane Oxygenation

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📖 REFERENCES

Guideline/Source	Year
GINA (Global Initiative for Asthma)	2023
GOLD (Global Initiative for COPD)	2024
ESC Guidelines on Acute and Chronic Heart Failure	2021
ESC Guidelines on Pulmonary Embolism	2019
BTS/SIGN Asthma Guidelines	2019
BTS Guidelines on NIV	2016
Indian Chest Society Guidelines	Various
API Textbook of Medicine	Latest Edition

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Document Version: 1.0

India-Specific Notes:

• Duolin (Salbutamol + Ipratropium) widely available
• Asthalin (Salbutamol) respules common
• Generic steroids widely available
• NIV availability variable – transfer if not available
• CTPA availability limited in primary care – clinical diagnosis and transfer important for PE

Disclaimer: This protocol provides general guidance. Clinical judgment must be exercised. Local protocols and resources may vary.