Acute breathlessnessOxygen, ECG monitor, Check BP, Listen over lungs, IV cannula, Nebulized salbutamol if wheeze Sign of tension Decompress with large-bore needle, 2nd pneumothorax intercostal space in mid-clavicular line Major arrhythmia? Treat No Clinical assessment, Chest X-ray, Arterial blood gases, 12 lead ECG Chest X-ray clear Chest X-ray abnormal Consider: - Acute asthma - Exacerbation of COPD - Upper airways obstruction - Pulmonary embolism Specific diagnosis and -Pre-radiological pneumonia treatment - Sepsis syndrome
Urgent investigations in acutebreathlessness 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 FeaturesAcute 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 wheezePulmonary 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-rayExacerbation of chronicobstructive pulmonary Increase in sputum volume, tenacitydisease 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 Pleuritic or non-pleuritic chestembolism pain Haemoptysis Risk factors for venous thromboembolism present (signs of DVT commonly absent) Sudden breathlessness in youngPneumothorax 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
Cardiactamponade Raised JVP Pulsus paradoxus > 20mmHg Enlarged cardiac silhouette on chest X-ray Known carcinoma of bronchus or breastLaryngeal History of smoke inhalation or the ingestion ofobstruction corrosives Palatal or tongue oedema Anaphylaxis
Tracheobronchial Stridor (inspiratory noise) or mnophonicobstruction 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 Distinguished from pulmonary consolidationeffusion 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-rayDisorder PaO2 PaCO2 PHaAcute asthma Normal/low Low High May be Normal orAcute exacerbation of COPD Usually low high low Normal/low (without pre-existingPulmonary embolism cardiopulmonary disease) Low HighPre-radiological pneumonia Low Low HighSepsis syndrome Normal/low Low LowMetabolic acidosis Normal Low LowHyperventilation withoutorganic disease High/normal Low High
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