56. Shortness of breath

Question 1

50 year old woman presents with episodes of sudden onset SOB, associated with chest tightness and tingling in her fingers, that are worse at night. They resolve spontaneously after a few minutes. She has a family history of asthma and a 15 pack year history.

a) What is the likely diagnosis and why?
b) How would you manage this?

Answer 1

a) Panic attacks - sudden onset and spontaneous resolution

b) - Treat any potentially treatable physical diseases (e.g. thyroid disease)
- Treat any comorbid psychiatric disorders (e.g. substance abuse, anxiety, depression)
- Coping strategies - breathing exercises and stress management
- Psychological therapies (e.g. CBT)
- Pharmacological therapies (e.g. SSRI if anxiety/ depression)

Question 2

SOB: differentials

a) Acute - cardiac, respiratory, other
b) Chronic - cardiac, respiratory, other

Answer 2

a) - Cardiac: ACS, acute HF (flash pulmonary oedema), arrhythmia, valvular (eg. AS), pericarditis, pericardial effusion
- Resp: acute exacerbation asthma/COPD, pneumonia, PE, pneumothorax, pleural effusion, lobe collapse, ARDS, foreign body, lung/airway trauma
- Other: pain, panic attack, DKA, anaphylaxis

b) - Cardiac: CCF, angina, valvular (eg. AS), arrhythmia
- Resp: asthma, COPD, IPF, cancer, bronchiectasis, pleural effusion
- Other: anaemia, neuromuscular (eg. MND) or chest wall disease, obesity

Question 3

SOB: history

a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx

Answer 3

a) - Onset: sudden (?PE, ACS, pneumothorax, etc.) or gradual (?CCF, malignancy, COPD, IPF, etc.), precipitating event (eg. trauma)
- Timing: duration, progressive, diurnal (?asthma), nocturnal (?CCF, asthma)
- Exacerbating factors: exercise (?CCF, respiratory), cold weather (?asthma, COPD), allergens (?asthma), lying flat (?CCF)
- Relieving factors: salbutamol (?asthma, COPD), sitting up (?CCF)
- How far can they normally walk on the flat? (has this changed?)
- How many pillows do they need at night?

b) - Wheeze, chest tightness, cough (?COPD, asthma)
- Fever, generally unwell, productive cough (?pneumonia)
- Leg swelling, orthopnoea (?CCF)
- Palpitations, chest pain, syncope (?cardiac)
- Acute leg swelling/pain, chest pain (?PE)
- Weight loss, anorexia, haemoptysis (?lung Ca)
- Bone pain, confusion, headaches, RUQ pain (?mets)

c) - CVD: previous MI, angina, HTN, diabetes, known AF, valve replacement, etc.
- Resp: known asthma/COPD, previous infection, previous VTE
- If asthma - previous ITU admissions, etc (assess control)

d) - Lung fibrotics: methotrexate, nitrofurantoin, amiodarone
- COCP/HRT (?PE)

e) - FHx heart disease, sudden death

f) - Smoking, alcohol
- Occupation (asbestos, allergens, occupational asthma)
- Pets
- Independence - can they climb flight of stairs?

Question 4

MRC dyspnoea scale (0 - 4)

Answer 4

• Grade 0: not troubled by breathlessness except on strenuous exertion.
• Grade 1: short of breath when hurrying on level ground or walking up a slight incline.
• Grade 2: walks slower than contemporaries because of breathlessness, or has to stop for breath when walking at own pace.
• Grade 3: stops for breath after walking about 100 metres or stops after a few minutes of walking on level ground.
• Grade 4: too breathless to leave the house or breathless on dressing or undressing.

Question 5

Examination of breathless patient

Answer 5

A - E (give oxygen as necessary)

General

• Patient distress, colour of skin and lips, cyanosis, clubbing, lymphadenopathy, tremor, flap
• Respiratory rate
• Pulse - rate, rhythm.
• Height and weight (body mass index)
• JVP

Chest

• Trachea - central, deviated to one side.
• Shape of chest - eg, kyphosis.
• Movement of chest - symmetrical, asymmetrical.
• Percussion note - eg, stony dull over a pleural effusion, hyper-resonant over a pneumothorax.

Auscultation of chest

• Wheezing/rhonchi - eg, asthma, COPD, heart failure, bronchiolitis
• Crepitations - eg, pneumonia, bronchiectasis, fibrosis, pulmonary oedema
• Stridor - eg, foreign body, acute epiglottitis, anaphylaxis, trauma
• No added sounds - eg, anaemia, pulmonary embolus, metabolic acidosis, neuromuscular causes

Question 6

Investigations in breathless patient

• bedside
• bloods
• imaging

Answer 6

Bedside

• Lung function tests - eg, peak flow measurement, spirometry.
• Pulse oximetry.
• ECG
• Sputum sample

Bloods.

• FBC, CRP, U+Es, clotting
• ABG
• ?cultures
• ?D-dimer
• ?BNP

Imaging.

• CXR
• ECHO
• ?CTPA
• ?HRCT
• ?CT CAP

Question 7

Managing a breathless patient.

a) Acute
b) Chronic
c) Palliative

Answer 7

a) - Sit up
- Relax
- High-flow oxygen
- ?bronchodilator inhalers/nebs (if wheezy)
- ?CPAP/NIV

b) - Pulmonary rehab
- Chest physio
- Treat underlying condition
- Diuretics if overloaded
- Optimise nutrition
- LTOT
- NIV

c) - Benzo
- Opiate