Acute presentation of Acute presentation of breathlessnessbreathlessnessAmmad Mahmood

Medicine at a Glance.

Medicine at a Glance; 2nd edition, pg20

Acute breathlessnessAcute breathlessness

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

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

Acute asthma – Acute asthma – Typical featuresTypical 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 featuresTypical 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 aCO2 >4.6kPa (32mmHg)

• P aO2 <8kPa (60mmHg), or SaO2<92%

• Low pH <7.35

InvestigationInvestigation Peak expiratory flow measurement if well

enough CXR to exclude pneumothorax and

infection Bloods – FBC, U+E Arterial blood gases

Test Result

PaO2 8.3 kPa (10.5-14)

PaCO2 3.8 kPa (4.7-6)

pH 7.51 (7.37-7.42)

H+ 32nmol/l (35-45)

HCO3- 24mmol/l (24-28)

ManagementManagement

BTS/SIGN Guideline - http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx

Management Management

BTS/SIGN Guideline - http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx

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

Exacerbation of COPD – Exacerbation of COPD – Typical featuresTypical 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 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

ManagementManagement

Look for a cause – infection, pneumothorax

Plan discharge – smoking cessation, oxygen therapy, vaccinations, steroids

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

Pulmonary Embolism – Pulmonary Embolism – Typical featuresTypical features

Risk factors – immobility, surgery, OCP, malignancy, previous thromboembolism

Acute dyspnoea Pleuritic chest pain Haemoptysis Syncope Tachycardia, hypotension

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

Pulmonary Oedema – Pulmonary Oedema – Typical FeaturesTypical 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 Precipitants of acute decompensation of heart decompensation of heart failurefailure

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 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

ManagementManagement

Long term:• ACEI / ARB• Beta-blocker• Aldosterone antagonist• Diuretics

• Digoxin• Nitrates

Other Causes of Acute Other Causes of Acute BreathlessnessBreathlessness Pneumothorax Respiratory Infection Airway obstruction Anaphylaxis

Any Questions?

Resources:• Medicine at a Glance• OHCM Emergencies Section• Kumar and Clark• emedicine.medscape.com