Lecture: breathlessness Flashcards
How would you classify breathlessness?
- Acute (seconds or minutes)
- Subacute (hours or days)
- Chronic (weeks or months)
Or:
- Respiratory
- Cardiac
- Miscellaneous
What are respiratory causes of breathlessness?
- Acute asthma
- Pneumonia
- COPD
- PE
- Pleural effusion
- Lobar collapse
- Upper airway obstruction
- ARDS
- Exacerbation off bronchiectasis
What are cardiac causes of breathlessness?
- Heart failure (pulmonary oedema)
- Silent MI (especially in diabetes)
- Pericardial effusion (due to malignancy)
- Tachyarrhythmia
- Cardiac tamponade
- Acute valvular dysfunction
What are causes of acute valvular dysfunction?
- infective endocarditis
- Acute MI (papillary muscle dysfunction)
- Aortic dissection (acute aortic regurg)
What are miscellaneous causes of breathlessness?
- Anaemia
- Metabolic acidosis (DKA, acute renal failure)
- Acute blood loss
- Thyrotoxicosis
- Neuromuscular disease
- Anxiety and hyperventilation
What can cause silent MI?
Diabetes
What are the most common causes of breathlessness presenting to A&E?
- COPD
- Pulmonary oedema
- Pneumonia
- MI
- Atrial fibrillation (can be caused by alcoholism) and flutter
- Pulmonary embolism
- Malignant tumour
How would you structure a breathlessness history?
- Duration, pattern, severity of SOB (what can’t you do now, which you could do in the past?) (NYHA heart failure classification!)
- Cough, sputum, haemoptysis, wheeze
- Systemic upset - fever, night sweats, malaise
- HF symptoms - orthopnoea, PND, peripheral oedema
- Other cardiac symptoms - chest pain, palpitations
- PE risk factors
- PMHx (CCF, COPD, asthma, IHD)
- Smoking history
How would you structure a breathlessness examination??
- Do they look well or unwell?
- ABCDE approach
- Heart rate
- Respiratory rate
- Oxygen saturation
- Blood pressure
- Fever and GCS
What are signs of respiratory distress?
- Stridor
- Nasal flaring
- Cyanosis
- Accessory muscle use
- Tracheal tug (paeds)
- Intercostal recession
- Interrupted sentences
What can a systolic BP differential be indicative of?
aortic dissection or wide pulse pressure (acute AR)
What can a pulsus paradoxus be indicative of?
cardiac tamponade, asthma exacerbation
What can an elevated JVP be indicative of?
acute LVF, PE, cor pulmonale, cardiac tamponade
What can reduced chest expansion be indicative of?
pneumothorax, collapse, effusion, cardiac tamponade
What are the core investigations for breathlessness?
- Routine bloods
- Biomarkers
- ECG
- ABG
- CXR
What are three common and important biomarkers and what do they indicate?
- D-dimer (PE; high sensitivity and high NPV)
- NT-proBNP (heart failure; high sensitivity and high NPV)
- Serial troponin (MI or myocardial injury, NOT per se ACS)
What is a globular heart on a CXR indicative of?
Pericardial effusion
What is widening of the mediastinum on a CXR indicative of?
Aortic dissection
When would you consider an emergency echo?
99% not necessary!
- Patient in cardiogenic shock (look at LV function)
- Cardiac tamponade (no pulmonary effusion; clear chest but cardiomegaly)
- Acute valvular dysfunction
- Massive PE (RV strain)
- Type A aortic dissection (but should really do CT scan)
What oxygen do you give when a patient is breathless?
- 15L per minute via non-rebreather mask if O2 <94% unless COPD
- 4L per minute 28% Venturi mask if COPD
What are signs of an MI?
- Dynamic T wave inversion
- ST elevation
- ST depression
How would you rate control in AF?
1st line: ß-blocker or CCB
2nd line: digoxin
