Acute presentation of breathlessness Ammad Mahmood

Medicine at a Glance. Medicine at a Glance; 2 nd edition, pg20

Acute breathlessness  4 cases of acute breathlessness: Typical presentation Investigations Acute management

A 30 year old woman with a history of asthma is admitted to the medical receiving ward with a 24 hour history of increasing SOB and wheeze…

Acute asthma – Typical features  History of asthma – ask about PEF and previous admissions (ITU?)  Normal between attacks  Exacerbating stimulus – exercise, pollen, cold, drugs, infection, emotion  Severe attack: Unable to complete sentences Respiratory rate >25/min Pulse rate >110 beats/min Peak expiratory flow <50% of predicted or best

Typical features  Life threatening attack Peak expiratory flow <33% of predicted or best Silent chest, cyanosis, feeble respiratory effort Bradycardia or hypotension Exhaustion, confusion, or coma Arterial blood gases: normal/high P a CO 2 >4.6kPa (32mmHg) P a O 2 <8kPa (60mmHg), or S a O 2 <92% Low pH <7.35

Investigation  Peak expiratory flow measurement if well enough  CXR to exclude pneumothorax and infection  Bloods – FBC, U+E  Arterial blood gases TestResult PaO28.3 kPa ( ) PaCO23.8 kPa (4.7-6) pH7.51 ( ) H+32nmol/l (35-45) HCO3-24mmol/l (24-28)

Management BTS/SIGN Guideline -

Management

A 74 year old woman is admitted having collapsed at home. Her daughter tells you she has been treated for ‘bronchitis’ for several years. She has become increasingly drowsy over the last few days and has a productive cough with green sputum. She smokes 20 cigarettes per day. She is centrally cyanosed, tachycardic, pyrexial and restless.

Exacerbation of COPD – Typical features  Increasing cough  Wheeze unrelieved by inhalers  Progressive dyspnoea on background SOB (‘pink puffers’) or…  Respiratory failure without dyspnoea (‘blue bloaters’)  Decreased exercise capacity  Confusion  Smoker  Usually triggered by viral or bacterial infection

Investigations  Peak expiratory flow (PEF) if well enough  Arterial blood gases  CXR – infection, pneumothorax  FBC, U&E, CRP  ECG  Blood cultures (if pyrexial)  Send sputum for culture

Management  Look for a cause – infection, pneumothorax  Plan discharge – smoking cessation, oxygen therapy, vaccinations, steroids

A 21 year old previously fit and well medical student who returned by plane yesterday from Australia presents with a 12 hour history of severe breathlessness, haemoptysis and pleuritic chest pain. On examination he is cyanosed, hyperventilating, tachycardic, hypotension and apyrexial.

Pulmonary Embolism – Typical features  Risk factors – immobility, surgery, OCP, malignancy, previous thromboembolism  Acute dyspnoea  Pleuritic chest pain  Haemoptysis  Syncope  Tachycardia, hypotension

Investigations  CT Pulmonary Angiography (CTPA) is sensitive and specific in determining if emboli are in pulmonary arteries  If unavailable, a ventilation–perfusion (V/Q) scan  ECG – sinus tachycardia, right axis deviation, Q waves and inverted T waves in V3  Serum D-dimer: high sensitivity but low specificity  FBC, U+E, baseline clotting  CXR  ABG

Management  SIGN guidelines: Suspected PE should be managed with heparin and fondaparinux until the diagnosis is deemed unlikely Moderate-risk PE patients should not receive thrombolytics Long term they should receive warfarin (or LMWH in cancer patients or patients with poor compliance) for at least 3 months with target INR 2.5 Compression stockings should be worn following DVT for 2 years

A 72 year old lady is admitted with a 48 hour history of worsening shortness of breath. On examination you find her to be severely unwell, coughing pink frothy sputum, with a marked tachycardia and profuse fine crackles at both lung bases. No murmurs are audible.

Pulmonary Oedema – Typical Features  Usually due to left ventricular failure, other causes – fluid overload, trauma, malaria, drugs, head injury  Distressed, pale, sweaty  Dyspnoea  Orthopnoea  Pink frothy sputum  Tachycardia  Tachypnoea  Raised JVP  Fine basal lung crackles

Precipitants of acute decompensation of heart failure  Inappropriate reduction in management eg drugs, fluid restriction  Uncontrolled hypertension  Arrhythmias  MI  Valvular disease  Systemic illness eg sepsis  High output states eg anaemia, thyrotoxicosis

Investigations  CXR – cardiomegaly, signs of pulmonary oedema (bilateral shadowing, small effusions at costophrenic angles, fluid in the fissures, Kerley B lines, batwing opacities)  Bloods – FBC, U+E, ABG, cardiac enzymes, BNP  ECG – look for MI, arrhythmias  Consider echocardiography

Management  Long term: ACEI / ARB Beta-blocker Aldosterone antagonist Diuretics Digoxin Nitrates

Other Causes of Acute Breathlessness  Pneumothorax  Respiratory Infection  Airway obstruction  Anaphylaxis

Any Questions?  Resources: Medicine at a Glance OHCM Emergencies Section Kumar and Clark emedicine.medscape.com