WEEK 4 - Shortness Of Breath

Question 1

Causes of shortness of breath?

Answer 1

• Acute Pulmonary Oedema
• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Croup
• Pleurisy
• Pneumonia
• Pneumothorax

Question 2

What is acute pulmonary oedema?

Answer 2

Pulmonary oedema occurs when the alveoli fill up with excess fluid that has seeped out of the pulmonary blood vessels - raised capillary hydrostatic pressure causes transudation of fluid into pulmonary interstitial spaces and then into the alveoli. This reduces gas exchange, resulting in breathing difficulty and poor oxygenation of blood.

Question 3

causes of ‘non-cardiogenic pulmonary oedema’ include;

Answer 3

• acute respiratory distress syndrome (ARDS)
• kidney failure
• high altitude
• brain trauma
• severe seizures
• brain surgery
• rapid expansion of the lung
• aspirin overdose
• pulmonary embolism
• viral infections
• eclampsia in pregnancy.

Question 4

What is pulmonary oedema most often associated with?

Answer 4

Often related to heart failure (commonly post an MI), termed ‘cardiogenic pulmonary oedema’, and is seen most often in the elderly with a cardiac history

Question 5

The most common symptom of pulmonary oedema

Answer 5

• SOB

Question 6

common symptoms may include

Answer 6

• easy fatigue
• dyspnoea on exertion
• tachypnoea
• dizziness
• weakness
• hypoxia
• crackles on auscultation of the lungs

Question 7

Symptoms of APO/ ACPO in severe cases

Answer 7

the crackles are loud and auscultation is not required, the patient can barely breath, is extremely hypertensive, and there may be frothy sputum coming out of the mouth!

Question 8

Prehospital treatment of APO

Answer 8

• high-flow oxygen
• GTN
• may require CPAP.

Question 9

What is asthma?

Answer 9

Asthma is a chronic inflammatory disease that affects the bronchioles

Question 10

The typical pattern of an asthma attack involves the following:

Answer 10

• When asthma is “triggered” by any number of external or internal factors, the bronchioles swell and fill with mucus.
• Muscles within the bronchioles contract (bronchospasm), causing even further narrowing of the airways.
• This narrowing makes it difficult for air to be exhaled from the lungs.
• This resistance to exhaling leads to the typical symptoms of an asthma attack.

Question 11

triggers of asthma

Answer 11

• exposure to smoke
• breathing polluted air
• inhaling other respiratory irritants such as perfumes or cleaning products
• breathing in allergy-causing substances (allergens) such as molds, dust, or animal dander
• an upper respiratory infection, such as a cold, flu, sinusitis or bronchitis
• exposure to cold, dry weather
• emotional excitement or stress, and physical exertion/exercise

Question 12

Risk factors for developing asthma:

Answer 12

hay fever (allergic rhinitis) and other allergies - this is the single biggest risk factor
eczema - another type of allergy affecting the skin
genetic predisposition - a parent, brother, or sister also has asthma

Question 13

When the airways become irritated or infected, an attack is often triggered, which may come on suddenly, or develop slowly over several days or hours. The main symptoms of asthma are:

Answer 13

• wheezing (the most common sign)
• breathlessness
• chest tightness
• coughing
• difficulty speaking

Question 14

Current guidelines for the care of people with asthma include classifying the severity of asthma symptoms, as follows:

Answer 14

• mild intermittent
• mild persistent
• moderate persistent
• severe persistent

Question 15

‘Preventer and controller medicines’ in asthma

Answer 15

Long-acting beta-agonists
Inhaled corticosteroids

Question 16

Long acting beta agonists

Answer 16

• this class of drugs is chemically related to adrenaline
• Inhaled long-acting beta-agonists work to keep airways open for 12 hours or longer
• They cause bronchodilation - decreasing the resistance to exhaled airflow, making it easier to breathe
• They may also help to reduce inflammation, but they have no effect on the underlying cause of the asthma attack
• Side effects include tachycardia and shakiness/tremors.

Question 17

Inhaled corticosteroids:

Answer 17

• the inhaled steroids act locally by concentrating their effects directly within the airways, with very few side effects outside of the lungs.
• Prednisolone, Hydrocortisone, Beclomethasone (Vancenase, Beclovent) and triamcinolone (Nasacort, Atolone) are examples of inhaled corticosteroids.
  Flixotide, Pulmicort, Singulair, Salmeterol (Serevent) and formoterol (Foradil) are examples of preventers and controllers.

Question 18

‘Reliever medications’ are taken after an asthma attack has already begun and include:

Answer 18

• Short-acting beta-agonists
• Anticholinergics

Question 19

Short-acting beta-agonists:

Answer 19

• inhaled short-acting beta-agonists work rapidly, within minutes, to bronchodilate, and the effects usually last four hours
• Salbutamol (Proventil, Ventolin) is the most frequently used short-acting beta-agonist medication.

Question 20

Anticholinergics

Answer 20

• another class of drugs useful as rescue medications during asthma attacks.
• Inhaled anticholinergic drugs open the airways, similar to the action of the beta-agonists, and help to dry-up mucous.
• Inhaled anticholinergics take slightly longer than beta-agonists to achieve their effect, but they last longer than the beta-agonists.
• An anticholinergic drug is often used together with a beta-agonist drug to produce a greater effect than either drug can achieve by itself. Ipratropium bromide (Atrovent) is the inhaled anticholinergic drug currently used as a rescue asthma medication.

Question 21

Prehospital treatment of an asthma attack:

Answer 21

In the prehospital setting a patient will often receive salbutamol and atrovent in a nebuliser for mild to moderate asthma, and IM or IV adrenaline for severe asthma with respiratory compromise/failure. Oral steroids may also be considered.

Question 22

What is Chronic obstructive pulmonary disease (COPD)?

Answer 22

Chronic obstructive pulmonary disease, or COPD, is a long-lasting obstruction of the airways that occurs with chronic bronchitis, emphysema, or both. This obstruction of airflow is progressive in that it happens over time.

Question 23

Causes of COPD include:

Answer 23

cigarette smoking or exposure to tobacco smoke (15% of cigarette smokers)
airway hyper-responsiveness (increased risk for, and deterioration from COPD); and possibly
air pollution

Question 24

Common signs and symptoms of COPD are:

Answer 24

Breathlessness or being short of breath - is the most significant symptom (but it does not usually occur until the sixth decade of life)
A productive cough
Wheezing (especially during exertion and when the condition worsens)

Question 25

The following symptoms may occur as COPD worsens:

Answer 25

Intervals between acute periods of worsening of dyspnea (exacerbations) become shorter
Cyanosis
Right sided heart failure
Anorexia and weight loss often develop and suggest a worse prognosis

Question 26

Prehospital management of COPD

Answer 26

They are treated with salbutamol and atrovent nebulisers (just like asthma) and may even require adrenaline - however the risks associated with this may be greater.

Question 27

What is croup?

Answer 27

is caused by an acute viral infection of the upper respiratory tract. It is also called laryngotracheobronchitis since it affects the larynx, trachea, and bronchi. This infection results in inflammation, increased mucus production and swelling of the upper airways. Although croup usually resolves on its own, between 5%-10% of children with croup will require admission to hospital. Common viral causes include parainfluenza, influenza, adenovirus, respiratory syncytial virus (RSV) and rhinovirus.

Question 28

The signs and symptoms of croup are:

Answer 28

a cold with low-grade temperature (gradually developing)
rhinorrhoea
barking cough
stridor (worse when patient becomes upset)
dysphagia
respiratory distress

Question 29

The symptoms of croup become more pronounced as the severity of the condition increases:

Answer 29

Mild severity - occasional barking cough, no audible stridor at rest, and either no or mild suprasternal and/or intercostal retractions
Moderate severity - frequent barking cough, easily audible stridor at rest, and suprasternal and sternal wall retractions at rest, with no or minimal agitation
Severe severity - frequent barking cough, prominent inspiratory (and occasionally expiratory) stridor, marked sternal wall retractions, significant agitation and distress

Question 30

Prehospital treatment of croup

Answer 30

hese patients generally only require intervention in the severe stage (nebulised adrenaline), but should always be transported for further assessment and may be given oral steroids (prednisolone)

Question 31

What is pleuritis?

Answer 31

The pleura is a two layered sac that holds the lungs and separates them from the chest wall, diaphragm, and heart. Pleuritis (or pleurisy) results from an inflammation of this sac.

Question 32

causes of pleuritis:

Answer 32

• Infectious disease caused by virus, bacteria, fungus, tuberculosis or parasites
• Cancers (e.g. mesothelioma from asbestos)
• Collagen vascular disease (e.g. lupus, rheumatoid arthritis, sarcoid disease, scleroderma)
• Trauma (bruised or broken ribs)
• Gastrointestinal disease (e.g. pancreatitis, peritonitis or a collection of pus under the diaphragm)
• Reaction to drugs (e.g. methotrexate, penicillin) and radiation therapy
• Medical conditions such as uremia, PE, sickle cell disease and HIV

Question 33

The main symptoms of pleuritis are:

Answer 33

• chest pain (most common symptom despite the cause being from a respiratory issue) - generally a sharp, stabbing pain which worsens with deep breathing, coughing and moving around. The pain is lessened by taking shallow breaths and lying on the side that hurts.
• shortness of breath - may often be due to the underlying cause (e.g. PE), from an associated chest infection, or pain (people will breathe shallow to minimise discomfort which limits their ability to respire appropriately and they feel short of breath).
• cough - this depends on the cause of the pleuritis the patient may have a cough (dry or productive).
• fever - may or may not be present depending on the cause of the pleuritis.

Question 34

Prehospital treatment of pleuritis

Answer 34

In the prehospital setting a patient with pleuritis would call for chest pain and/or shortness of breath, and due to their presentation and history the paramedic should be able to determine a pleuritic cause for their pain. Management involves posture and analgesia, symptom control, and transport for chest X-ray and further assessment.

Question 35

What is pneumonia?

Answer 35

Pneumonia is an inflammatory condition of the lung parenchyma, primarily affecting the alveoli, and is essentially a severe chest infection. It can be caused by either bacteria (almost two thirds) or a virus (one third) and frequently begins as an upper respiratory tract infection (URTI) before moving into the lower respiratory tract.

Question 36

Typical pneumonia presentation:

Answer 36

Comes on very quickly.
Usually leads to the production of yellow or brown sputum when coughing.
There may be chest pain and back pain, which is usually worse with breathing, coughing or palpation.
Can cause shortness of breath, especially in those with respiratory issues.
Fever
Older people may have altered mentation.

Question 37

Atypical pneumonia presentation:

Answer 37

Has a gradual onset.
It is often referred to as “walking pneumonia” (the x-ray looks worse than the patient presents)
Sometimes it follows another illness in the days to weeks before the pneumonia.
The fever is usually lower and rigors are less likely.
There may be headache, body aches and joint pain.
Coughing may be dry or produce only a little sputum.
Chest pain and abdominal pain may be present.
There may be other symptoms, such as feeling tired or weak.

Question 38

Prehospital treatment of pneumonia

Answer 38

Paramedics will treat pneumonia by the patient’s presentation and associated symptoms present, usually with oxygen therapy to ensure maximal oxygen exchange at the non-affected alveoli. Patients should be transported for a chest X-ray and blood tests to determine the type of infection. Remember the importance of wearing PPE (face mask) on these types of cases!

Question 39

Symptoms of pneumonia

Answer 39

coughing, mucus production, fever, shortness of breath and/or chest pain

Question 40

When inflammation occurs in the alveoli, they often fill with fluid. The lungs become less elastic and cannot take oxygen into the blood or remove carbon dioxide from the blood as efficiently as usual, creating the feeling of shortness of breath. Inflammation and mucous production (your body’s attempt to destroy the pathogen), causes many of the other symptoms, including fever and chest pain.

Question 41

What is a pneumothorax?

Answer 41

A pneumothorax is an abnormal collection of air in the pleural cavity, resulting in a portion, or all of a lung to ‘collapse’.

Question 42

What is the primary cause of a pneumothorax?

Answer 42

• is trauma to the chest cavity (e.g. fractured rib puncturing the lung, complication of a diagnostic medical procedure, or penetrating chest trauma)
• Sometimes, very tall, thin people (usually males) are prone to a spontaneous pneumothorax.

Question 43

Risk factors of pneumothorax:

Answer 43

are cigarette smoking and recreational drug use.

Question 44

What are the two types of pneumothorax

Answer 44

simple and tension.

Question 45

Simple pneumothorax:

Answer 45

• usually only partial collapse of a lung. minimal pressure build-up in the lung cavity.
  the collapsed lung is unable to ventilate (decreased oxygen exchange) with subsequent shortness of breath.
• can be small and “stable”, and not require emergency treatment. However, the pneumothorax may slowly or rapidly progress to cause more severe cardiovascular impairment and may often need to be monitored.

Question 46

Tension pneumothorax:

Answer 46

• a one-way valve is created and air continues to enter the pleural space with each breath - intrathoracic pressure increases substantially.
• pressure is exerted onto the unaffacted lung and IVC - decreasing preload to the heart and causing cardiovascular collapse (tamponade effect).
• if an affected person does not receive emergency treatment (chest needle decompression), death may result.

Question 47

Signs and symptoms of a pneumothorax include:

Answer 47

• Severe shortness of breath
• Sharp, stabbing chest pain that worsens on breathing or with deep inspiration (pleuritic chest pain)
• Pain radiating to the shoulder and/or back
• A dry, hacking cough may occur because of irritation of the diaphragm
• If a tension pneumothorax is present, signs of cardiovascular collapse and shock will occur. These include: Jugular Vein Distension, cyanosis, tachycardia, hypotension, and altered GCS - subsequent rapid deterioration.

Question 48

Pre hospital treatment if pneumothorax

Answer 48

In the ambulance environment management of a simple pneumothroax is limited - analgesia and supplemental oxygen may be required, depending on the patient’s pain levels and the size of the pneumothorax. In the case of a tension pneumothorax this needs immediate attention to ABCs and chest needle decompression to prevent complete cardiovascular collapse and cardiac arrest! This is more likely in the case of trauma with a substantial mechanism.