Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Acute severe respiratory distress
Sudden breathlessness, stridor, haemoptysis, pleuritic pain, unilateral absent breath sounds, cyanosis, exhaustion, altered consciousness or haemodynamic instability may represent a reversible respiratory emergency.
Action: Use ABCDE assessment, sit the person upright when tolerated, provide calm continuous support and activate emergency help within the agreed treatment ceiling. Give oxygen for hypoxaemia, treat the suspected cause promptly and provide symptom relief in parallel; do not assume acute deterioration is terminal solely because illness is advanced.
Synopsis
Assess breathlessness as a subjective multidimensional symptom, treat reversible emergencies and disease mechanisms, combine non-pharmacological measures with proportionate opioid or oxygen trials, and document goal-concordant escalation before crisis.
Breathlessness is the patient's perception; respiratory rate, oxygen saturation and imaging help find mechanisms but do not measure distress completely.
First-line assessment defines onset, triggers, positional and exertional pattern, associated pain, cough, haemoptysis, wheeze, fever and current treatment ceiling.
Treat reversible causes when likely benefit matches goals: bronchodilator, antibiotic, diuretic, anticoagulation, drainage, transfusion, stent or radiotherapy may be appropriate.
Key red flags
Stridor, facial or neck swelling, inability to speak, drooling or rapidly worsening upper-airway noise requires immediate airway and senior oncological assessment.
Respiratory exhaustion
Falling effort, silent chest, altered consciousness or inability to speak after sustained distress signals impending ventilatory failure.
Investigation priorities
01
First-line bedside respiratory assessmentFirst stepFirst line
Measure rate, effort, speech, arousal, oxygen saturation, pulse, pressure and temperature and examine airway, chest, heart, legs and fluid status.
Management branches
Acute deteriorationTreat emergency and distress together
Breathlessness has developed suddenly, intensified rapidly or is accompanied by instability or red flags.
Use ABCDE, position and reassure, provide oxygen to the appropriate target when hypoxaemic and activate emergency support within known treatment limits.
Treat the suspected mechanism promptly and obtain focused tests that can change antibiotics, diuresis, anticoagulation, drainage, airway treatment or ventilatory support.
Key medicines
Immediate-release oral morphine for refractory breathlessnessIn an opioid-naive frail adult, a local palliative protocol may begin with 2 to 2.5 mg orally as needed or at a defined interval and titrate from response; verify the exact regimen, maximum and review timing and use a renal-appropriate alternative when morphine is unsuitable.
Lorazepam for severe breathlessness-related anxietyWhen anxiety remains severe despite non-drug measures and other causes are addressed, use 500 micrograms orally or sublingually as a patient-specific as-needed dose under the local palliative protocol, with a clear minimum interval and review.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
NICE NG31 care of dying adultsIndividual breathlessness assessment, non-drug care, opioid, benzodiazepine and oxygen considerations.