Breathlessness Flashcards
Assessment emergency admission
Perform an initial Airway, Breathing, Circulation assessment, and determine the need for emergency admission.
Measure BP, temp, pulse rate, level of consciousness, O2 sat, RR
Emergency admission if:
Rapid onset or worsening of symptoms of suspected heart failure, Suspected sepsis, Anaphylaxis, ECG suggesting a cardiac arrhythmia or myocardial infarction.
Clinical features of:
Pulmonary embolism.
Pneumothorax.
Cardiac tamponade.
Pulmonary oedema.
Superior vena cava syndrome.
Any features of a severe asthma attack:
Altered level of consciousness.
Arrhythmia.
Cyanosis.
Elevated respiratory rate.
Exhaustion.
Hypotension.
Oxygen saturation less than 92%.
Peak expiratory flow rate less than 50% of predicted.
Silent chest.
Any features of a severe COPD exacerbation:
Acute confusion, Cyanosis, Oxygen saturation less than 90%.
Poor general condition including significant comorbidity (such as cardiac disease or diabetes).
Rapid onset of symptoms.
Severe breathlessness.
Worsening peripheral oedema.
Arrange urgent admission for people with suspected community-acquired pneumonia and a CRB65 score of 3 or more, and consider admission for people with a score of 1 or 2.
Assessment not emergency admission
Perform an initial Airway, Breathing, Circulation assessment, and determine the need for emergency admission.
Assess the person’s blood pressure, pulse rate, respiratory rate, temperature, level of consciousness, and oxygen saturation.
Take a history and ask about:
Duration and onset — acute dyspnoea typically indicates life-threatening conditions.
Severity — this is highly subjective and varies widely for a given level of functional impairment.
Factors that exacerbate or alleviate — eg, positional changes.
Dyspnoea on lying flat and relieved by sitting up = left heart dysfunction.
Paroxysmal nocturnal dyspnoea — the person is woken from sleep and needs to sit upright = pulmonary oedema.
Exercise tolerance — distance they can walk, climbing stairs.
Impact on daily activities — for example, dressing.
Pattern of dyspnoea — for example, mornings, the working week (potential occupational exposure), seasonal dyspnoea (exposure to cold), and extrinsic triggers (pets, perfumes).
Associated symptoms — for example, chest pain, palpitations, syncope, fever, wheezing, cough.
Comorbidities
Recent surgery.
Drug history (including any illegal drug use) — for example, beta-blockers, digoxin, calcium-channel blockers.
Smoking, alcohol intake, physical activity.
Travel history.
Examine the person — conduct cardiovascular, respiratory, and neurological examinations. Arrange additional investigations that may be appropriate depending on the presentation, examination and suspected underlying cause.
Investigations if emergency admission is not required
Urgent chest X-ray (within 2 weeks) to assess for lung cancer - aged >=40 years - have two or more of the following unexplained symptoms OR if they have smoked and one or more of:
Cough.
Fatigue.
Chest pain.
Weight loss.
Appetite loss.
Other:
Abdominal ultrasound — to confirm the presence of ascites and to exclude or confirm liver cirrhosis and peritoneal cancer.
B-type natriuretic peptide (BNP) — to assess for heart failure.
Chest x-ray — to look for signs of heart failure, pulmonary pathology (including pleural effusion, lung collapse), pneumothorax, and to exclude other causes (for example in people with suspected pneumonia or bronchiectasis).
CRP
ECG — eg for signs of heart failure, pulmonary hypertension, arrhythmia, cardiac tamponade, and PE.
Full blood count — anaemia, infection.
Kidney function tests — to exclude renal impairment.
Liver function tests — bilirubin + Transaminases may be elevated in liver failure.
Peak expiratory flow rate (PEFR) and spirometry — to assess for possible asthma or obstructive airway disease.
Pulse oximetry — hypoxaemia may occur in a range of conditions, including pneumonia, pulmonary oedema, COPD, asthma, and interstitial lung disease.
Thyroid function test — to detect thyroid disease.
Acute pulmonary oedema
Risk factors — chronic heart failure, ischaemic heart disease, valvular heart disease, arrhythmia, pulmonary embolism.
Symptoms — severe breathlessness, orthopnoea, coughing (rarely with frothy blood-stained sputum).
Signs — elevated jugular venous pressure, gallop rhythm, crackles, central cyanosis, and occasionally wheeze, peripheral oedema, chest pain, syncope.
Pulmonary oedema.
Give an intravenous diuretic (for example furosemide 20 mg to 40 mg).
Cardiac arrhythmia
Risk factors — heart failure, valvular heart disease, coronary artery disease, previous arrhythmia.
Symptoms — may be sudden onset, palpitations, breathless, chest pain, syncope
Signs — bradycardia or tachycardia.
ECG — for SVT includes regular narrow QRS complex tachycardia and rate greater than 100 bpm.
Wide complex tachycardias may have a supraventricular or ventricular origin.
Supraventricular tachycardia (SVT) — attempt to terminate the arrhythmia using a Valsalva manoeuvre or carotid sinus massage.
Valsalva manoeuvre — ask the person to blow into a syringe for 15 seconds whilst lying down, face up.
Carotid sinus massage — do not attempt this in the is elderly, in people with recent ischemia or digoxin toxicity. Only attempt one side at a time.
Cardiac tamponade
Risk factors — malignancy, collection of fluid after cardiac surgery, trauma, autoimmune disease, myxoedema, myocardial infarction.
Symptoms — breathlessness, collapse.
Signs — tachycardia, pulsus paroxodus, tachypnoea, engorgement of neck veins and face, peripheral cyanosis, shock.
Chronic heart failure
Risk factors — advanced age, hypertension, coronary heart disease, valvular heart disease, chronic cardiac arrhythmia, diabetes, obesity, family history of cardiomyopathy or sudden death.
Symptoms — fatigue and breathlessness, orthopnoea, paroxysmal nocturnal dyspnoea, reduced exercise tolerance.
Signs — oedema, basal crepitations, laterally displaced apical pulse, third heart sound (gallop rhythm), elevated jugular venous pressure, ankle swelling, weight changes, hepatojugular reflex and hepatomegaly.
Silent myocardial infarction (MI)
Risk factors — coronary artery disease, smoking, hyperlipidaemia, hypertension, obesity, diabetes, family history.
Atypical presentations of myocardial infarction such as isolated breathlessness or fatigue are more common in the elderly, in women and in people with diabetes, chronic renal disease or dementia.
Symptoms — breathlessness, general malaise, sudden collapse, upper body discomfort, nausea.
Signs — abnormal pulse rate, sweating, reduced peripheral perfusion, hypotension.
ECG — features suggestive of acute MI include ST depression with T-wave inversion, persistent ST elevation, or new left bundle branch block. Q-waves do not give an indication of the age of an MI as remain permanent following infarction. A normal ECG does not exclude myocardial infarction.
Silent myocardial infarction — give aspirin 300 mg.
Superior vena cava syndrome
Risk factors — lung cancer, history of smoking, lymphoma, metastatic tumours.
Symptoms — breathlessness, chest pain, cough, headache worse on stopping, hoarseness.
Signs — neck and facial swelling, dilated collateral chest veins, facial plethora, fixed elevation of jugular venous pressure, anorexia.
Pulmonary causes - asthma
Risk factors — personal history of rhinitis or eczema, or family history of atopy or asthma.
Symptoms — wheeze, breathlessness, chest tightness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens, or taking some medications such as nonsteroidal anti-inflammatory [NSAID] medication and beta-blockers).
Signs — during an acute episode, the respiratory rate is increased, wheeze is usually present, and peak expiratory flow rate (PEFR) is reduced.
Life-threatening features of acute asthma include: PEFR less than 33% of best or predicted; oxygen saturation less than 92%; silent chest, cyanosis, or poor respiratory effort; arrhythmia or hypotension; exhaustion, or impaired level of consciousness.
Severe features of acute asthma include PEFR 33–50% of best or predicted, respiratory rate of 25 breaths per minute or greater, pulse 110 beats per minute or greater, or inability to complete full sentences in one breath.
Moderate features of acute asthma include PEFR 50%-75% of predicted, without any features of severe or life-threatening acute asthma.
Acute severe asthma (peak expiratory flow rate less than 50% of predicted).
Give a bronchodilator by wet nebulization driven by oxygen (for example salbutamol 5 mg).
Repeat the bronchodilator treatment at 15-30 minute intervals if initial response is inadequate.
Give prednisolone 40-50 mg orally (if available), or parenteral hydrocortisone 100 mg.
Bronchiecstasis
History — suspect in people with a history of recurrent or chronic productive cough, absence of smoking history, previous pulmonary infections.
Symptoms — cough with daily sputum production, progressive breathlessness, haemoptysis, non-pleuritic chest pain between exacerbations.
Signs — coarse crackles, rhonchi, wheeze, prolonged expiratory phase. Finger clubbing, cyanosis and hypoxia may be present.
COPD
History — typically, the person is older than 35 years of age, is a smoker (or past smoker) and reports slowly progressive breathlessness.
Symptoms — persistent progressive exertional breathlessness that is often associated with wheezing and a cough (productive of sputum). Acute exacerbations of symptoms are common, and are frequently caused by respiratory tract infection. Frequent winter ‘bronchitis’ may be described.
Signs — there may be no abnormal signs but they can include wheeze, hyperinflated chest, purse lip breathing, cachexia, cyanosis, peripheral oedema, increased jugular venous pressure (JVP), peripheral oedema, tachypnoea, and use of accessory muscles. Crackles may be present when exacerbation is infective.
Identify and treat people with clinical features of:
Acute exacerbation of COPD.
Increase the dose or frequency of bronchodilator therapy — use a metered-dose inhaler via a spacer, or air-driven nebulizer when appropriate.
Give oral prednisolone 30 mg (if available).
Interstitial lung disease (ILD)
Causes — smoking, idiopathic pulmonary fibrosis, sarcoidosis, pneumoconiosis, medication, connective tissue disease, hypersensitivity pneumonitis/extrinsic allergic alveolitis (following sensitization to inhaled environmental allergens).
Symptoms — cough and slowly progressive breathlessness. There may be symptoms of the underlying cause (for example joint pains if associated with connective tissue disease).
Signs — dry crackles, hypoxaemia, there may be finger clubbing and cyanosis.
Lung/lobar collapse
Causes — airway compression (for example by enlarged lymph nodes caused by cancer or tuberculosis) or blockage (secondary to pneumonia or an inhaled foreign body).
Symptoms — breathlessness, cough.
Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds, mediastinal displacement towards the collapse.
Pleural effusion
Causes — heart failure,
liver cirrhosis,
hypothyroidism,
pneumonia, pulmonary embolism, cancer (including mesothelioma), tuberculosis, pleural infection (empyema), and
autoimmune disease.
Symptoms — these depend on the rate of fluid accumulation and volume, but include progressive breathlessness and pleuritic pain, as well as symptoms of the underlying condition.
Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, decreased tactile vocal fremitus/vocal resonance and bronchial breathing just above the effusion.
If the pleural effusion is large, the trachea may deviate away from the effusion.
There may be signs of the underlying condition.
