Med A - Breathlessness

Question 1

67 y/o female ex-smoker

pc: increasing SOB over past few days, cough, not sputum, no relief form inhalers, no chest pain or haemoptysis.

obs: 100bpm, 24 RR, accessory muscle use, cyanosed 92% on oxygen. struggling to speak.
bilateral swollen ankles, JVP not elevated. heart sounds normal. trachea central.

chest wheezy, no crackles, breath sounds reduced on left.

PMH: IHD, COPD, BMI 55, anxiety, panic attacks

differential diagnoses?

Answer 1

1. non-infective exacerbation of COPD
2. acute LVF with cardiac asthma
3. possible pneumothorax with unilateral reduced breath sounds and sudden deterioration.

No chest pain and haemoptysis helps rule out

• PE
• silent MI with LVF

Question 2

67 y/o female ex-smoker

pc: increasing SOB over past few days, cough, not sputum, no relief form inhalers, no chest pain or haemoptysis.

obs: 100bpm, 24 RR, accessory muscle use, cyanosed 92% on oxygen. struggling to speak.
bilateral swollen ankles, JVP not elevated. heart sounds normal. trachea central.

chest wheezy, no crackles, breath sounds reduced on left.

PMH: IHD, COPD, BMI 55, anxiety, panic attacks

immediate management?

Answer 2

a) continue O2
b) continuous monitoring of patient
c) nebulised bronchodilators
d) intravenous diuretics
e) urgent tests : CXR, ECG, ABG, FBC, U&Es, troponin, BNP, D-Dimer

Question 3

first line antibiotics for treatment of acute exacerbation of COPD?

Answer 3

Amoxicillin

Doxycycline

Clarithromycin

Question 4

what scale does Nice recommend for assessing the impact of breathlessness?

Answer 4

MRC dyspnoea scale

Grade 1 – Breathless on strenuous exercise

Grade 2 – Breathless on walking up hill

Grade 3 – Breathless that slows walking on the flat

Grade 4 – Stop to catch their breath after walking 100 meters on the flat

Grade 5 – Unable to leave the house due to breathlessness

Question 5

long term management for COPD patients?

Answer 5

• pneumococcal and annual flu vaccine
  1. short acting bronchodilators: beta 2 agonists (salbutamol or terrbutaline) or short acting antimuscarinics (ipratropium bromide)
  2. LABA + LAMA if they don’t have asthmatic or steroid responsive features

LABA + inhaled corticosteroid if they have asthmatic or steroid responsiveness features

Question 6

medical treatment of COPD exacerbation if well enough to remain at home?

Answer 6

• prednisolone 30mg OD 7-14 days
• regular inhalers or home nebulisers
• antibiotics

Question 7

medical treatment of exacerbation in hospital?

Answer 7

• nebulised bronchodilators (salbutamol, ipratropium)
• steroids (hydrocortisone, oral prednisolone)
• antibiotics
• physiotherapy

Question 8

what might you give as an option in severe cases where patient is not responding to first line treatment of COPD exacerbation?

Answer 8

• IV aminophylline
• non-invasive ventilation
• intubation and ventilation
• doxapram