Guidelines for the Initial Assessment of Respiratory Distress in the Emergency Department
SFMU/SRLF · 2026 · France
Source and licence
- Authors
- P. Le Borgne, A.W. Thille, J. Guenezan et al.
- Title
- Guidelines for the Initial Assessment of Respiratory Distress in the Emergency Department
- Journal
- Annals of Intensive Care, 2026
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC12934415
Licence statement of the original publication
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
Open the original publication →Full text on Europe PMC
Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Methods
- After defining the objectives and the methodological framework of the project, the organizing committee determined the scope of these Clinical Practice Guidelines and formulated the questions to be addressed. Each question was assigned to several experts for review and drafting. All questions followed the PICO format (Population, Intervention, Comparison, Outcome). A systematic literature review was conducted using the PubMed™, Cochrane™, and www.clinicaltrials.gov databases. Eligible publications were written in English or French. Priority was given to recent evidence, with an appraisal hierarchy ranging from meta-analyses and randomized controlled trials (RCTs) to observational studies. The sample size and relevance of each study were assessed individually. For each reference, the level of evidence was determined based on study type and methodological quality. Recommendations were formulated using the terminology and grading system established by the SFMU and the FICS. High-level evidence led to strong recommendations (GRADE 1+ or 1−: "it is recommended to…" or "it is not recommended to…"), whereas moderate or low-level evidence supported conditional recommendations (GRADE 2+ or 2−: "it is probably recommended to…" or "it is probably not recommended to…"). In the absence of sufficient evidence, expert opinions were provided using the phrasing: “the experts suggest…”.
Results
- The expert synthesis and application of the GRADE methodology led to the formulation of 20 recommendations and 3 instances where no recommendation could be issued, based on a total of 13 clinical questions. Following two rounds of voting and a limited number of amendments, strong agreement was reached for the majority of recommendations and the proposed algorithm. Among the 20 recommendations, 2 were supported by high-quality evidence (GRADE 1), 6 by moderate quality evidence (GRADE 2), and 12 were based on expert opinion. For 3 questions, the panel was unable to formulate a recommendation due to insufficient or inconclusive evidence.
Field 1 - assessment of severity
- R1.1.1The experts suggest that the following clinical severity signs should be actively sought during the emergency call interview, as they may justify dispatching a physician-staffed advanced life support unit: tachypnea (respiratory rate >25 breaths/min), thoraco-abdominal asynchrony, inability to speak full sentences, peripheral cyanosis, profuse sweating, and altered level of consciousness. These signs should be assessed either directly with the patient or via a bystander, and videoconferencing may be used to assist in their identification
Rationale
- R1.2.1The experts suggest that direct admission to the intensive care unit (ICU) should be proposed for patients receiving invasive mechanical ventilation, and considered for those under non-invasive ventilation, those requiring persistently high oxygen flows, or those presenting with at least one additional organ failure beyond the respiratory system during prehospital management.
- R1.3.1Patients presenting with tachypnea (respiratory rate >25 breaths per minute) are at increased risk of requiring endotracheal intubation compared to patients without tachypnea. The risks of ICU admission and in-hospital mortality are also higher in this population.
- R1.3.2The experts suggest that patients who present with altered consciousness, paradoxical abdominal breathing, or use of accessory inspiratory muscles have an increased risk of in-hospital mortality compared to those without these clinical signs.
Field 2 - initial assessment, triage and monitoring
- R2.1.1The experts suggest that patients presenting with respiratory distress - whether or not they exhibit severity criteria - should be triaged using a structured triage scale upon admission to the Emergency Department, in order to reduce morbidity and mortality.
Rationale
- R2.2.1The experts suggest that patients presenting with respiratory distress but without severity criteria (triage levels 3A and 3B) should undergo regular monitoring of vital signs, including systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR), body temperature, level of consciousness, and peripheral oxygen saturation (SpO₂), during their stay in the Emergency Department (ED), in order to reduce morbidity and mortality.
- R2.2.2The experts suggest that patients presenting with respiratory distress and severity criteria (triage levels 1 and 2) should undergo continuous monitoring of vital signs, including SBP, HR, RR, body temperature, level of consciousness, and SpO₂, throughout their stay in the ED, in order to reduce morbidity and mortality. The experts further encourage that respiratory rate (RR) be measured over a minimum duration of 30 seconds upon arrival and continuously monitored during the entire emergency care period.
- R2.2.3The experts suggest using a numerical scale to assess the most suggestive components of dyspnea in patients admitted to the ED, regardless of the presence or absence of severity criteria.
Field 3 - diagnostic approach
- R3.1.1In patients with a very low clinical suspicion of pulmonary embolism (PE), the use of the Pulmonary Embolism Rule-out Criteria (PERC) is recommended to safely exclude the diagnosis without the need for further testing.
- R3.1.2In patients with suspected pulmonary embolism (PE), the YEARS and PEGeD diagnostic strategies are probably preferable. These approaches have been shown to be safe and to reduce the number of unnecessary diagnostic tests, compared to strategies based on the revised Geneva score or the Wells score combined with age-adjusted D-dimer thresholds (Fig. 1).
- R3.1.3In patients with suspected pulmonary embolism (PE), the experts suggest that the chosen diagnostic strategy - regardless of which validated algorithm is used (e.g., PERC, YEARS, PEGeD, Geneva, or Wells) - should be followed through to completion in order to ensure the safety and reliability of the diagnostic process.
Rationale
- R3.2.1Venous blood gas analysis is not recommended for assessing the degree of hypoxemia
- R3.2.2Peripheral oxygen saturation (SpO₂) alone is probably sufficient to assess the degree of oxygenation. In patients breathing ambient air, an SpO₂ >96% makes a PaO₂ <60 mmHg unlikely. In patients with chronic obstructive pulmonary disease (COPD), an SpO₂ >92% similarly makes significant hypoxemia unlikely.
- R3.2.3The experts suggest that venous blood gas analysis may be used to assess carbon dioxide levels. A normal venous PvCO₂ (<45 mmHg) makes a PaCO₂>50 mmHg unlikely.
- R3.2.4Arterial blood gas analysis is probably the reference standard, particularly in complex clinical situations
- R3.3.1No recommendation can be issued regarding the use of venous blood gas analysis in addition to peripheral oxygen saturation (SpO₂) measurement to improve clinical decision-making
- R3.3.2The experts suggest that arterial blood gas analysis should not be performed systematically to guide clinical decision-making (treatment, patient disposition) or monitoring in patients presenting with respiratory distress with or without signs of severity. Arterial blood gas analysis may be considered in the presence of respiratory distress to confirm the need for ventilatory support or to guide patient disposition, particularly in cases where SpO₂ is unreliable or cannot be measured, or to confirm and quantify hypercapnia and respiratory acidosis when venous PCO₂ is elevated.
- R3.41 - There is insufficient evidence to recommend the measurement of C-reactive protein (CRP) to guide the initiation of antibiotic therapy in patients presenting to the ED with acute dyspnea with or without associated respiratory distress and suspected lower respiratory tract infection
- R3.42 - There is insufficient evidence to recommend regarding the use of procalcitonin (PCT) to guide the initiation of antibiotic therapy in patients presenting to the ED with acute dyspnea with or without associated respiratory distress and suspected lower respiratory tract infection.
- R3.5.1Measurement of natriuretic peptides is probably recommended to help rule out the diagnosis of acute heart failure (AHF), given their excellent negative predictive value across various clinical settings, except in obese patients. This measurement should only be performed and interpreted in conjunction with clinical information.
- R3.6.1The use of integrated cardiac and lung ultrasound is probably recommended to assist in determining the underlying cause of acute dyspnea.
- R3.7.1The experts suggest performing a low-dose chest CT scan in cases of diagnostic uncertainty regarding suspected community-acquired pneumonia, or as a first-line imaging modality when the standard strategy does not provide sufficiently high-quality images.
- R3.8.1The experts suggest assessing functional dependency and frailty in elderly patients presenting with respiratory distress to the ED in order to predict in-hospital survival. Beyond chronological age, there are no specific prognostic criteria identified for in-hospital mortality.
Abstract
Objective: The French Society of Emergency Medicine (SFMU) and the French Intensive Care Society (SRLF) present formalized expert recommendations from a multidisciplinary panel on the initial assessment of respiratory distress in adult patients presenting to the Emergency Department.
Design: A group of 30 French experts from the SFMU and FICS was assembled. Any potential conflicts of interest were officially declared at the start of the guidelines development process, which was conducted independently of any industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology to assess the level of evidence from the literature.
Methods: The aim of this expert panel was to define evidence-based recommendations for the initial assessment of respiratory distress in the emergency setting. Three key areas were defined: (1) assessment of severity in respiratory distress; (2) initial assessment and triage in respiratory distress; (3) diagnostic approach for respiratory distress. For each area, the goal of the recommendations was to address a set of questions formulated by the experts following the PICO model (“Population, Intervention, Comparison, Outcome”). Based on these questions, a comprehensive literature search was conducted for the last 20 years using predefined keywords according to PRISMA guidelines. The quality of the data was analyzed using the GRADE method. The recommendations were formulated using the GRADE methodology, and then voted on by all experts using the GRADE Grid method.
Results: The expert consensus process, based on the GRADE methodology, resulted in 13 clinical questions yielding 20 recommendations. For three of these questions, however, no recommendation could be issued due to insufficient evidence. After two rounds of voting and several amendments, a strong consensus was reached on the recommendations. Among these, two were supported by high-quality evidence and resulted in a strong recommendation (GRADE 1); six were based on moderate-quality evidence and led to a conditional recommendation (GRADE 2); and twelve were based on expert opinion, reflecting a low level of evidence. Finally, for 3 questions, no recommendation could be formulated.
Conclusion: A strong consensus was reached among the experts on 20 of the recommendations. This work provides updated recommendations for the initial assessment of respiratory distress in adult patients presenting to the Emergency Department.
Contents of the original publication
The section headings of the original.
- Introduction
- Methods
- Results
- Field 1 - assessment of severity
- Rationale
- Rationale
- Rationale
- Field 2 - initial assessment, triage and monitoring
- Rationale
- Rationale
- Field 3 - diagnostic approach
- Rationale
- Rationale
- Rationale
- Rationale
- Rationale
- Rationale
- Rationale
- Rationale
- Reviewers
- CRediT authorship contribution statement
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