Breathlessness : emergency presentations

Wheezing? Asthma COPD Heart Failure Anaphylaxis

Stridor? (Upper airway obstruction) Foreign body or tumour Acute epiglottitis Anaphylaxis Trauma, eg laryngeal fracture

Crepitations? Heart failure Pneumonia Bronchiectasis Fibrosis

Chest clear? Pulmonary embolism Hyperventilation Metabolic acidosis, eg diabetic ketoacidosis (DKA) Anaemia Drugs, eg: salicylates Shock (may cause air hunger) Pneumocystis pneumonia Central causes

Others Pneumothorax – pain, increased resonance Pleural effusion – 'stony dullness'

Priority management of acute breathlessness

Acute breathlessness

Oxygen, ECG monitor, Check BP, Listen over lungs, IV cannula, Nebulized salbutamol if wheeze

Sign of tension pneumothorax

Major arrhythmia?

Decompress with large-bore needle, 2nd intercostal space in mid-clavicular line

Treat

Clinical assessment, Chest X-ray, Arterial blood gases, 12 lead ECG

Chest X-ray abnormal

Specific diagnosis and treatment

Chest X-ray clear

Consider: - Acute asthma

- Exacerbation of COPD

- Upper airways obstruction

- Pulmonary embolism

-Pre-radiological pneumonia

- Sepsis syndrome

No

Urgent investigations in acute breathlessness Chest X-ray Arterial blood gases and pH if oxygen saturation is

<90% or diagnosis is unclear ECG(except in patients under 40 with pneumothorax

or acute asthma) Full blood count Creatinine, sodium, potassium and glucose Echocardiogram if:

Suspected cardiac tamponade Suspected surgically correctable cause of pulmonary

oedema

Features pointing to a diagnosis in the breathless patient

Diagnosis Features

Acute asthma Wheeze with reduced peak flow rate

Previous similar episodes responding to bronchodilator therapy

Diurnal and seasonal variation in symptoms

Symptoms provoked by allergen exposure or exercise

Sleep disturbance by breathlessness and wheeze

Pulmonary oedema Cardiac disease

Abnormal ECG

Bilateral interstitial or alveolar shadowing on chest x-ray

Pneumonia Fever

Productive cough

Pleuritic chest pain

Focal shadowing on chest X-ray

Exacerbation of chronic obstructive pulmonary disease

Increase in sputum volume, tenacity or purulence

Previous chronic bronchitis: sputum production daily for 3 months of the year, for 2 or more consecutive years

Wheeze with reduced peak flow rate

Pulmonary embolism

Pleuritic or non-pleuritic chest pain

Haemoptysis

Risk factors for venous thromboembolism present (signs of DVT commonly absent)

PneumothoraxSudden breathlessness in young otherwise fit adult

Breathlessness following invasive procedure e.g subclavian vein puncture

Pleuritic chest pain

Visceral pleural line on chest x-ray, with absent lung markings between this line and the chest wall

Cardiac tamponade Raised JVP

Pulsus paradoxus > 20mmHg

Enlarged cardiac silhouette on chest X-ray

Known carcinoma of bronchus or breast

Laryngeal obstruction

History of smoke inhalation or the ingestion of corrosives

Palatal or tongue oedema

Anaphylaxis

Tracheobronchial obstruction

Stridor (inspiratory noise) or mnophonic wheeze (expiratory 'squeak')

Known carcinoma of the bronchus

History of inhaled foreign body

PaCo2>5 kPa in the absence of chronic obstructive pulmonary disease

Wheeze unresponsive to bronchodilators

Large pleural effusion

Distinguished from pulmonary consolidation on the chest x-ray by:

Shadowing higher laterally than medially

Shadowing does not conform to that of a lobe or segment

No air bronchogram

Trachea and mediastinum pushed to opposite side

Arterial blood gases and pH in breathlessness with a normal chest X-ray

Disorder PaO2 PaCO2 PHa

Acute asthma Normal/low Low High

Acute exacerbation of COPD Usually lowMay be high

Normal or low

Pulmonary embolismNormal/low (without pre-existing cardiopulmonary disease) Low High

Pre-radiological pneumonia Low Low High

Sepsis syndrome Normal/low Low Low

Metabolic acidosis Normal Low Low

Hyperventilation without organic disease High/normal Low High