1. Breathlessness in the Emergency Department
Dr Orlaith Scullion
11/09/15

2. Dyspnoea in the Emergency Department
Aims
To consider common presentations of dyspnoea in adults presenting to the ED
To describe appropriate initial management and treatment
To identify patients with severe or life threatening conditions
To recognise when to involve ICU

3. BTS Guidelines - CAP Community aquired
No pre-disposing conditions eg. cancer, immunosuppression
Does NOT apply to those with non-pneumonic LRTI eg. acute exacerbations of COPD / chest infections without CXR changes
BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001:56;iv1-iv64

4. BTS Guidelines - pathogens
S pneumoniae
H influenzae
Legionella spp
S aureus
M catarrhalis
Gram negitive enteric bacilli
M pneumoniae
C pneumoniae
C psittaci
All viruses
Influenza A and B
mixed

5. BTS Guidelines – Clinical and Radiological Features
Not able to predict aetiological agent from clinical / radiological features
Elderly patients are more likely to present with non-specific symptoms and less likely to have fever than younger patients
Radiological resolution often lags behind clinical improvement
Radiological changes caused by atypical pathogens clear more quickly than bacterial pathogens

6. BTS Guidelines Investigations (Community Rx)
CXR not necessary
SaO2
Microbiology not recommended, mycobacterium tuberculosis and Legionella if indicated
Investigations (Hospitalise Rx)
CXR / FBC / U+E / LFT / CRP / oxygenation
Blood culture and other microbiology as indicated eg. sputum, urine, serology

7. BTS Guidelines - severity
Confusion (abb MSE 8 or less)
Urea > 7 mmol/l
Resp rate ≥ 30/min
BP > 90 systolic and / or ≥ 60 diastolic
Pre-existing:
Age ≥ 50
Co-existing disease

8. CURB-65 Confusion (abb MSE 8 or less) Urea > 7 mmol/l
Resp rate ≥ 30/min
BP > 90 systolic and / or ≥ 60 diastolic
Age ≥ 65

9. AAH Antimicrobial Guidelines
CURB-65 score
Rountine investigations for all RTI
FBC / CRP / Blood cultures (x2) / CXR / oximetry
Additional investigations when CURB-65 >3
Urinary antigen for Streptococcus pneumoniae and Legionella sp. / atypical pneumonia and Legionella serology / ABG

10. CURB-65 = 0 or 1 Not severe Consider discharge and home treatment
1st: amoxicillin 500mg – 1g TID oral 7/7
Alt: clarithromycin or doxycycline

11. CURB-65 = 2 Not severe Consider hospital supervised treatment
1st: amoxicillin 500mg – 1g TID oral 7/7
Alt: clarithromycin or doxycycline

12. CURB-65 = 3 Severe Inpatient treatment
1st: amoxicillin 1g TID IV plus clarithromycin 500mg BD IV 7/7
Alt: teicoplanin plus clarithromycin IV

13. CURB-65 = 4 or 5 Very severe Assess for ICU admission
1st: co-amoxiclav 1.2g TID IV plus clarithromycin 500mg BD IV 7/7
Alt: discuss with microbiology / ICU

14. Aspiration CAP
1st: amoxicillin 500mg – 1g TID IV plus metrondiazole 500mg TID IV
Alt: clarithromycin plus metrondiazole

15. Managing Exacerbations of COPD
Further Reading: NICE guideline 101 COPD in primary and secondary care 2010
Treat in hospital:
Unable to cope at home / living alone
Severe breathlessness
Deteriorating / poor general condition
Cyanosis
Worsening peripheral oedema
Impaired level of consciousness / acute confusion
Already receiving LTOT
Significant co-morbidities
Significant CXR changes
Sats < 90%, pH < 7.35 PaO2 <7

16. Initial Management Nebulisers: Salbutamol and ipratropium
Oxygen to maintain sats 92%
Antibiotics if purulent sputum or pneumonic changes on CXR: clarithromycin 500mg oral / iv +/- co-amoxiclav 1.2g iv
Steriods: prednisolone 30mg daily (100mg hydrocortisone iv)

17. Further Management Consider iv aminophylline
Magnesium 2g iv (not in guideline)
NIV if persistent hypercapnic ventilatory failure despite optimal medical treatment (MAU)
IPPV (ICU)
Chest physio to help clear secretions

18. Severe Asthma in Adults
Moderate
↑ symptoms
PEF >50-75% best or predicted
Severe
PEF 33-50% best or predicted
RR ≥ 25 / min
HR ≥ 110 / min
Inability to complete full sentences in one breath

19. Severe Asthma in Adults
Life threatening
PEF < 33% best or predicted
SpO2 < 92%
PaO2 < 8 kPa
normal PaCO2
Silent chest
Cyanosis
Poor respiratory effort
Arrhythmia
Exhaustion, altered conscious level.

20. Treatment of Acute Asthma
Admit if signs of life threatening asthma
Admit if persistent signs of severe asthma after initial treatment
Pts whose PEF > 75% best or predicted one hr after treatment may be d/c home from ED unless other reasons for admission

21. Treatment of Acute Asthma
Oxygen (sats 94 – 98%)
B2 agonists:
Nebulised salbutamol 5mg (oxygen driven) stat
? Need for continuous nebs
IV if not able to tolerate nebuliser
Ipratropium 500mcg neb 4-6 hrly
Steroids: 40 – 50 mg prednisolone
Magnesium 2g iv over 20 mins
Routine antibiotics not indicated

22. Referral to ICU Requiring ventilatory support
Acute severe or life threatening asthma failing to respond to therapy
Deteriorating PEF
Persisting / worsening hypoxia
Hypercapnea
Resp acidosis
Exhaustion / poor resp effort
↓ GCS or confusion
Resp arrest

23. Summary BTS guidelines Good initial assessment with obs
Treat appropriately
Get senior help early
Consider ICU

24. Pneumothorax
the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung.
Symtoms
Pleuritic Chest Pain
SOB
Decreased exercise tolerance
Cough
Palpitations

25. Signs Decreased expansion on affected side
Hyper-resonant percussion note
Tachycardia
Tension Pneumothorax
Cyanosis
Displaced Trachea
Distended neck veins

26. Management pg 97 Handbook
Page 97 of handbook

27. Chest Drain Insertion Not required for most patients
Should only be performed under guidance from experienced ED staff
Use the triangle of safety

28. Acute Cardiogenic Pulmonary Oedema
Cardiogenic (or hydrostatic) pulmonary oedema caused by an elevated pulmonary capillary pressure from left-sided heart failure
Most commonly due to an acute ischaemic event
Other causes include acute AR, MR, Tamponade, RAS, AKI
Iatrogenic

29. Signs Acutely dyspnoeic Sweaty Distressed/ agitated
Cough with frothy sputum
Tachycardia
Elevated JVP
Widespread crackles throughout chest

30. Management
ABC apply 02
ECG if acute STEMI refer for PCI give frusemide
Bloods including TnT ABG BNP
Drugs-Frusemide, Nitrate infusion ?Low dose diamorphine,
Consider CPAP

31. ICU
If patient not responding to treatment persistant severe hypoxaemia despite CPAP and appropriate medical management
Need for Ultrafiltration
Periarrest
Ensure Cardiology team also involved

32. Pulmonary Embolism
Pulmonary embolism is a condition in which one or more emboli, usually arising from a blood clot formed in the veins (or, rarely, in the right heart), are lodged in and obstruct the pulmonary arterial system.
This results in reduced gas exchange of the affected lung tissue, causing hypoxaemia and a reduction in cardiac output.
Large or multiple emboli may result in hypotension, syncope, shock, and sudden death.

33. Signs and Symptoms Pleuritic chest pain Shortness of breath
Palpitations
Leg swelling
Dizziness
Collapse

34. Management Suspect PE Examination Wells Score-high(>6) CTPA
Med/low -D-dimer:
if elevated CTPA
Treatment dose enoxaparin unless contraindicated.
PESI score to decide if suitable for outpatient management
If score greater than 85 admit medically.
If negative find alternative diagnosis

35. Lifethreatening PE Call senior ED staff Associated with collapse
Severe hypoxia
Lifethreatening arrhythmia
Severe Hypotension despite fluid resuscitation
Call ICU team
Alteplase 50mg thrombolysis

36. Any Questions?..