medical intern/tshilidzini

1. APPROACH OF PATIENT
WITH BREATHING
DIFFICULTIES
Dr PJCA Mbizi
Family medicine
October 2018

2. introduction
■ Acute breathlessness is a common
emergency condition .the effort required for
breathing often makes it virtually impossible
for the patient to provide any form of medical
history and questioning may only make the
situation worse.The clinician s skills will help
to determine the underlying cause and dictate
appropriate management .

3. Immediately life threatening causes and
signs of breathlessness
■ airway assessment
■ Breathing assessment
■ Circulation assessment
■ NB it is important to remember that the breathless patient does not always have
pathological arising primarily from the respiratory or cardiovascular systems

4. 1 . AIRWAYASSESSMENT
■ Airway problem are common in acute emergencies
■ Airway obstruction is the immediately life threatening problem due to :
■ Pharynx ; tongue swelling, swelling of the epiglottis or soft tissue
■ Larynx : oedema, spasm of the vocal cords, foreign body, trauma
■ Subglottic: secretions or foreign body , swelling
■ Bronchial : aspiration, tension pneumothorax, foreign body

5. Primary assessment and resuscitation
■ Look at the chest for the rate, depth and symmetry of movement ,look in
the mouth for blood , gastric contents, frothy sputum (pulmonary edema)
and foreign body
■ Listen for breath sounds , partial obstruction maybe as inspiratory noises
indicates upper airway obstruction ( stridor), expiratory noises for lower
airway obstruction (wheezing ), crowing (laryngeal spasm) , gurgling or
snoring
■ Feel for expired air, chest movement ,position of the trachea, any
subcutaneous emphysema
■ Airway control and ventilation are essential prerequisites for successful
management of the acutely ill, airway obstruction should be recognized
and managed immediately, endotracheal intubation remains the best
method of securing and controlling the airway, but requires additional
equipment, skill and practice.

6. Summary of airway assessment
■ Look respiratory rate , effort , symmetry
■ Feel expired air, trachea
■ Listen : count to 10 , breath sounds, added noises
■ Resuscitation :high concentrations of inspired oxygen may relieve some of the
patients s distress. If airway obstruction is suspected, request IMMEDIATE review by a
specialist. If a foreign body has been inhaled, attempt a Heimlich or modified Heimlich
manoeuvre

8. Foreign Body
Not impacted
Not visualized
Vocal cords could be
seen ?
Intubate and push it
into Right main
bronchus
Ventilate with 100% O2 or perform needle
cricothyrotomy if intubation fails
Could be visualized
Use Magill’s Forceps
and remove it
Impacted
Bimanual method
One hand externally at
the neck and the fingers
of the other hand into the
mouth

9. Assess
consciousness
If Crying/Coughing :
encourage coughing
Unable to cough-
Heimlich’s
maneuver
If unconscious
Basic airway support
Direct laryngoscopy and
Magill forceps
If unsuccessful, insert an ETT and push into the
right mainstem bronchus

10. 2. Breathing assessment
■ Look for the color (pallor or well colored =mucus), posture, respiratory rate , effort ,
symmetry
■ Feel for trachea position , chest expansion
■ Percuss and listen : anterior and posterior aspects of both lungs in the upper, middle
and lower zones.
■ Resuscitation : if bronchospasm is suspected, treat patients with oxygen driven
nebulized bronchodilators irrespective of the underlying cause, whilst clues to the
cause are sought, immediate management of a tension pneumothorax is needle -
followed by intravenous access and chest drain insertion.

11. 3. Circulation assessment
■ Look for pallor, sweating, venous pressure
■ Feel for pulse , rate ,rhythm and character, capillary refill time, blood pressure,apex
beat
■ Listen for blood pressure , heart sounds, extra sounds , lung bases
■ Resuscitation : all patients should receive high concentrations oxygen, be trated in a
seated position ( if level of consciousness permits) and have their oxygen saturation ,
pulse , blood pressure and cardiac rhythm monitored, intravenous acces is necessary
and at least one large cannula (12-14 gauge) is required.The management of the
shocked patient will depend on the underlying cause.Treatment options are as follow :

12. Shock management
■ Acute, severe , left ventricular failure : inotropes,
■ Dysrhytmia ( tachycardia= cardio-version, bradycardia = atropine, inotrope, pacing
■ Hypo-voleamia : fluids
■ Pulmonary embolus : anticoagulation, thrombolysis, fluids
■ Sepsis :fluids, antibiotics, inotropes
■ Anaphylaxis : adrenaline, fluids , chlorpheniramine, hydrocortisone
■ Cardiac tamponade : fluids, pericardio-centesis

13. Secondary assessment
■ Once the patient s conditions is stabilized and the primary assessment completed, further
information can be obtained from the secondary assessment
■ Summary : in the breathless patient , the immediately life threatening problem are ;
■ Airway : obstruction
■ Breathing : acute severe asthma, acute exacerbation of COPD, pulmonary edema, tension
pneumothorax, critical oxygen desaturation
■ Circulation : acute severe left ventricular failure, dysrhythmia, hypovolemia, pulmonary
embolus, cardiac tamponade
These conditions can be identified and differentiated clinically. all patients require oxygen and
IVI access .

14. Secondary assessment
■ Any patients with breathless will be able to give
a history,
■ Potentially life threatening causes of breathless
are :
■ RESPIRATORY :
■ asthma,
■ acute or chronic respiratory failure,
■ pulmonary edema,
■ Simple pneumopathy
■ Pneumonia
■ Pleural infusion
■ Pulmonary embolus
■ NON RESPIRATORY :
■ metabolic acidosis e.g diabetic
ketoacidosis, salicylate overdose
■ Hemorrhage
■ Acute or chronic gastro-enteritis

15. case
■ A old man with known ischaemic heart disease was admitted to the coronary care unit
after becoming acutely breathless, he denied any chest pain or cough, the following
physical signs were elicited:
■ RR 26/min
■ Fine inspiratory crackles wre heard at both bases
■ Pulse rate 140/min and regular
■ BP 80/50 mmhg
■ what would be your immediate management ?

16. References
■ Acute medical emergencies , the practical approach , sd edition
■ SaracinoA (October 2007). "Review of dyspnoea quantification in the emergency
department: is a rating scale for breathlessness suitable for use as an admission
prediction tool?". Emerg Med Australas 19 (5): 394–404.
■ Mahler DA, ed. Dyspnea. Mount Kisco, N.Y.: Futura Publishing, 1990.
■ Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. 2d ed.
Baltimore:Williams &Wilkins, 1986.