Breathlessness

Question 1

Case1: You are the IMT1 on call on the acute medical take. You have been asked to review a 25 year old female patient referred by their GP with an acute onset of sharp chest pain and shortness of breath. She has no significant past medical history. Her only regular medication is the combined oral contraceptive pill. She does not smoke.

Her observations in A&E are as follows:
Temp 37.2, RR 32, Sats 93% on air, HR 108, BP 112/65

An arterial blood gas has already been performed which demonstrates the following (taken on air, with no supplemental oxygen):

**pH 7.45 (7.35-7.45) , pO2 7.7 (10-14), pCO2 3.9 (4.5-6.0)

Na 138 (135-145), K+ 4.5 (3.5-5.5), Glu 5.9 (4-8)

HCO3 24 (22-26), BE -0.5 (-2 -> +2), Lactate 1.0 (<2.0)**

How would you initially assess and manage this patient? - A-C

Answer 1

1. ABCDE approach

A - patent airways, pt talking?

B - this patient is hypoxic, with evidence of type 1 respiratory failure and partial respiratory alkalosis due to hyperventilation.

• I would immediately start 15L oxygen via a NRB mask.
• Assess respiratory rate and work of breathing
• Assess trachea and chest expansion
• Percuss and auscultate the lungs for any focal abnormalities
• Repeat ABG following my treatment to see if it taking an effect

C
* Assess heart rate, blood pressure and central and peripheral CRT
* Obtain IV access with at least one large bore cannula and send off bloods at the same time (FBC, U&E, LFTs, CRP, coagulation screen, VBG, potentially blood cultures if infection suspected)
* If appropriate, 500ml crystalloid bolus and antibiotics (if infection suspected)
* Assess JVP and auscultate heart sounds, attach a continuous 3L ECG monitoring
* Assess fluid status and check for oedema

Question 2

Case1:
D-E for the same patient

Answer 2

D
* Assess the patient’s GCS
* Assess any focal neurological signs
* Measure blood glucose if not already done

E
* Assess patient’s temperature
* Complete the examination - specifically looking for any signs of trauma, examine the abdomen
* Examine the lower legs for any evidence of DVT or peripheral oedema

Question 3

Case1:
What is your DDx at this point?

Answer 3

1. Pulmonary embolism (COCP)
2. Pneumothorax
3. Infection - LRTI/CAP
4. Acute asthma attack
5. Aortic dissection
6. Cardiac - pericarditis / ACS - ACS unlikely at this patient but worth considering
7. MSK chest pain - diagnosis of exclusion

Question 4

Case1:
Please review the provided ABG. What does it show?

**pH 7.45 (7.35-7.45) , pO2 7.7 (10-14), pCO2 3.9 (4.5-6.0)

Na 138 (135-145), K+ 4.5 (3.5-5.5), Glu 5.9 (4-8)

HCO3 24 (22-26), BE -0.5 (-2 -> +2), Lactate 1.0 (<2.0)**

Answer 4

Respiratory alkalosis, evidence of type 1 respiratory failure on room air, no metabolic compensation, likely secondary to hyperventilation, which would explain the low pCO2

The electrolytes including lactate are all within normal limits

Question 5

Case1:
Are there any other investigations you would like to perform?

Answer 5

Bedside
* 12L ECG
* Covid swab

Bloods
* FBC, U&Es, CRP, LFTs, coagulation screen
* D-dimer considering on their Wells score
* Blood cultulres and VBG if I suspected sepsis

Imaging
* Urgent CXR
* Dependent on findings > CTPA

Question 6

Case1:
The patient has a CXR subsequently performed which shows:

Moderate right sided pneumothorax measuring 3.5cm. Otherwise clear lung fields.

Answer 6

At this stage, I would be involving my medical registrar.

After the update to Thoracic society (BTS) 2023, the size of pneumothorax is no longer an indication for invasive management, rather it’s clinical presentation.

This patient presented with breathlessness, chest pain, oxygen sats of 93% and a low PaO2. Therefore, I would choose intervention. The choice would be between needle aspiration and intercostal chest drain

Given that the patient is young, needle aspiration might be appropriate. However, she is in T1RF, so higher risk, so chest drain might be more appropriate

Question 7

Case1:
When can the patient be discharged?

What needs to be considered on discharge?

Answer 7

• Upon complete resolution of the pneumothorax and symptoms
• Counsel her re- risk of recurrence & safety net her by telling her to return in the event of any further symptoms
• Should not fly for seven days post resolution (confirmed on CXR)
• Warn that scubadiving permaninently not advised
• Repeat CXR 2-4 weeks post discharge

Question 8

**Case 1: **
You have one minute to hand over the patient to your registrar/consultant as if you were in the acute medical handover.

Answer 8

Situation: Hi I’m ‘x’, the IMT1 on the acute take. I need to hand over a 25 year old woman patient who has presented with a primary spontaneous pneumothorax.

Background: She presented with chest pain and has no significant known medical history.

Assessment: I have performed an A to E assessment which revealed tachypnoea and hypoxia so I started her on 15L oxygen via a non-rebreather mask. Her ABG showed a type 1 respiratory failure and chest x-ray revealed a 3.5cm pneumothorax.

Recommendation: This patient requires urgent treatment with either needle aspiration or a chest drain insertion. I would be grateful for your senior input with regards to any further advice on investigations and management.

Question 9

Case1:
Are you happy to discharge her?

This question is likely to be seen increasingly at interviews given the current bed pressures experienced by the NHS. Admissions must be for the right reason. At the same time, the consultants interviewing you don’t want a dangerous IMT trainee on their team, so be measured in your answer. It is important to impress that you would be cautious with this decision, and explain that you would discuss with a registrar or consultant first and also safetynet the patient.

Answer 9

As per the BTS guidelines, successful resolution of symptoms following needle aspiration in patients presenting with a primary spontaneous pneumothorax could be considered for discharge

I would advise patient to return immediately if symptoms recur, advise re- not flying for the next 7 days, permanently avoid scubadiving, and arrange a follow up and repeat CXR in 2-4 weeks in the Respiratory Clinic

Question 10

Case2:
You are the Medical SHO on take. Your registrar has asked you to see a 42 year old lady who has been admitted with worsening shortness of breath.

The nurse has called you from resus. The patient’s observations are as follows:

Respiratory Rate: 30 Saturations: 93% on room air. Blood Pressure: 105/62. Heart Rate: 112. Temperature 36.9 degrees.

He asks you to come and see the patient quickly as he thinks the patient is getting worse. He is worried that the patient is wheezy and having difficulty breathing.

How would you approach this pt?

Answer 10

ABCDE approach

A
- Ensure patent airway, if alert and talking, can be assumed
- If any signs of compromise - call for help (someone with airway skills)

B
- Monitor SpO2, check RR
- Give supplemental O2, target > 94%
- Look, listen, feel for signs of respiratory distress, consolidation, crepitations, fluid, wheezing
- ABG

C
- Check HR, BP
- 12-lead ECG
- IV access & take bloods
- Assess fluid status - CRT, JVOP, mucosal membranes
- Give IVF if dehydrated

D
- Temperature, glucose
- AVPU / GCS

Question 11

Case2:
What is your differential diagnosis for this patient?

Answer 11

Seconds to minutes
* Acute asthma, anaphylaxis
* Pneumothorax (+ Tension)
* Inhaled foreign body
* Pulmonary Embolism

Hours to day
* Pneumonia, Heart Failure, Pleural Effusion

Weeks to months
- Worsening COPD, chronic asthma, heart failure
- Pulmonary fibrosis, Anaemia, Pulmonary HTN, Obesity

Question 12

Case2:
What Questions in your history will help you towards your diagnosis?

Answer 12

Specific about this event:
* Time of onset of symptoms
* Alleviating / aggravating factors - worse when lying flat? worse on exertion?
* Any associated Sx? - Chest pain, pleuritic pain, cough, wheeze, weight loss, night sweats?
* Previous episodes like this?

PMHx & Drug Hx - any recent drug changes? Any allergies?

SHx
- Smoking?

FHx
- Any FHx of respiratory disease?

Occupational Hx
- What do they do?

Question 13

Case 2:
The patient’s symptoms came on suddenly this morning. She had been well yesterday. She has a past medical history of Asthma which is normally well controlled. She has being staying with her mother over the last two days. She started feeling wheezy this morning and unfortunately did not have her inhaler with her. She has become increasingly wheezy over the last 2 hours and is struggling to give you any more history due to her shortness of breath. On examination of her chest she has widespread wheeze, equal on both sides. She smokes 15 cigarettes a day.

What investigations will you do for this patient?

Answer 13

Bedside
* Monitor SpO2, give supplemental oxygen, aim > 94%
* Peak flow test to establish severity of asthma attack
* ABG
* 12-lead ECG

Bloods
- FBC, CRP, U&E
- If signs of infection: blood cultures

Imaging
- Chest X ray (consolidation, pneumothorax etc)

Question 14

Case 2:
What treatments will you start for this patient and how will you monitor their response to treatment?

Answer 14

Treatment response will be monitored by peak flow and oxygen requirements

Treatment:
Sit pt up
* High flow oxygen
* Salbutamol 5mg neb
* Prednisolone 40-50 mg (oral or IV - down to severity)
* If initial response poor > ipratropium bromide 0.mg every 4-6h nebulised
* Consider MgSO4 - Magnesium sulphate - if poor response

Reassess with peak flow and ABCDE

If no / poor progress > contact ITU registrar for airway management - can quickly become compromised.

If airway compromised&raquo_space; 2222 call

Question 15

Case 2:
What signs would suggest that the patient is deteriorating?

Answer 15

• Peak flow < 33%
• Fatigue, cyanosis,
• Soft breath sounds or silent chest
• Feeble respiratory effort
• Hypotension (sBP < 100)
• Decreasing level of consciousness
• ABG: SpO2 <** 90**% or PaO2 < 8kPA despite 100% NRB
• Rising PaCO2 - near-fatal asthma

Question 16

Case 2: How would you manage this patient long-term?

Answer 16

Can be discharged once PEF > 75% of best
* Short course of oral prednisolone
* Start pt on inhaled corticosteroid if not already on it
* Short acting Beta-2 agonist PRN for symptomatic control
* Long acting Beta-2 agonist can be added to the inhaled corticosteroid
* Observe inhaler technique
* Educate about PEF record keeping
* Follow up with GP (48 hours)
* Smoking cessation

Question 17

Case 2:
You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.

Answer 17

S – This is a 42 year old having an acute severe asthma attack who is deteriorating.

B – She has a known history of asthma and has been wheezing since this morning.

A – I have started initial treatment for this including high flow oxygen, salbutamol nebulisers and steroids. I have asked the staff to commence serial peak flows and to repeat the ABG.

R – I would recommend that this patient is reviewed urgently by the ITU team as they are at risk of further deterioration and may need to be admitted to ITU if they do not show signs of responding to initial treatments.