Breathlessness Philip Ryan

Aims Review what you already know

Put some context around it

Show you some Hereford specific information

E.g. care bundles

Answer any questions

Breathlessness

Dyspnoea is very common presenting symptom in ED, CAU and wards

Cough

Sputum Production

Haemoptysis

Wheeze

Chest Pain, oedema, PND, orthopnoea

Fever

Night Sweats

Hoarseness or Stridor

Whilst taking history - observe Inability to speak

Pursed lipped breathing

Accessory muscle use and intercostal recession

Positioning

Extreme tachypnoea (respiratory rate greater than 30 breaths per minute)

Hypoxaemia

Pulse Oximetry (sats< 90%, heart rate)

Examine with purpose i.e. to rule in or rule out diagnoses

temperature

Heart rate and rhthym, BP, valves, oedema

Breathe sounds

Absence

Crepitations

Wheeze

Pleural rub

Common causes of dysnoea COPD

Pneumothorax

Pneumonia

Pulmonary embolism

Asthma

Pleural Effusion

Acute pulmonary oedema

Acute coronary syndrome

Valvular heart disease

Also cause dysnoea Trauma (chest wall injuries and smoke inhalation)

Neurological causes (spinal cord injury, muscular dystrophy, GBS and stroke)

Endocrine causes (DKA)

Metabolic causes (metabolic acidosis from sepsis)

Toxicological causes (salicylate toxicity)

Haematological causes (anaemia)

Gastrointestinal causes (massive ascites)

Psychiatric causes (anxiety)

Investigations You may have some before you start your examination

Pulse oximetry

ABG if sats <92% (make sure you write FiO2)

CXR Write good clinical info

Report it yourself

FBC, CRP +/- blood culture +/- tropinin +/- d-dimer

ECG

Peak flow meter in asthma

Putting it all together https://youtu.be/peNFccdBL3A

Intern Content: Dyspnea - OnlineMedEd

Advice and Tips COPD

Usually a combination of age, smoking history and wheeze

Use the care bundle

Oxygen prescribing is key based on ABG

Make sure decisions about ventilation / ceiling of care are discussed on PTWR if not before

Pneumothorax

Very good BTS guidelines cover nearly all eventualities

Get early respiratoty help

Pneumonia

Use the care bundle

Admisister abx within 1 hour

Pulmonary embolism

Don’t use d-dimer indiscriminantly

If you need a CTPA- make it happen

Asthma

Make sure a peak flow chart is started, put peak flow recording on drug chart if necessary

Airway obstruction

Can be difficult to assess, early CT may be helful

Get early respiratory team help

NIV service

WVT: TP01: Ratified: June 2016 Updated: June 2016 (V. 1) Review Date: June 2018

Pulmonary Embolism Pathway

Symptoms and Signs of PE

Dyspnoea, pleuritic chest pain, haemoptysis, syncope, cough

Tachypnoea, tachycardia, fever, pleural rub

If massive PE suspected with haemodynamic instability consider thrombolysis (see note 1) and leave pathway

Request CXR, ECG, FBC, U&E, LFT, coagulation screen, bone profile, TropT, ABG if SpO2 <94%

Calculate Wells score (except in pregnant patients)

High probability of PE (pregnant patients or Wells

score >4) Low probability of PE (Wells score 4 or less)

Start treatment with low molecular weight heparin

relevant to body weight, renal function, pregnancy

status. If at high risk of bleeding seek senior advice.

For pregnant patients (note 3) request bilateral leg

Doppler ultrasound if leg symptoms/signs of DVT and,

if negative, low dose perfusion scan

All other patients request CTPA (if eGFR permits,

otherwise VQ)

Consider ambulatory management (see PESI score

and exclusion criteria (see note 2))

Check d-dimer

D-dimer positive D-dimer negative

PE excluded. Consider alternative

diagnosis and assess suitability for

discharge

PE confirmed

on CTPA (or VQ

high

probability)

Diagnostic doubt

(VQ moderate

probability) Perform

CTPA or treat as PE

PE excluded on

CTPA (or low

probability on VQ)

Consider oral anticoagulation (note 4)

Continue LMWH in patients with active cancer (note 5)

Continue LMWH in pregnant patients (note 6)

If unprovoked investigate according to NICE guidelines (note 7)

file:///.file/id=657136

7.13920318

Fluid, free in the

pleural cavity

Lung

Ribs

Anatomy of the Pleural Space

Pleural

Adhesions

Loculated

Effusion

Rib

Lung

Pleural Adhesion

Rib

Lung

Pleural

Adhesions

Loculated vs Free Pleural Effusion (Air or Liquid)

CT scan showing lung cancer

tumour

WVT: TP02: Ratified: June 2016 Updated: June 2016 (V. 1) Review Date: June 2018

Possible Cardiac Chest Pain Pathway

Pain or discomfort that sounds like unstable

angina or myocardial infarction

Observations including BP in both arms

Oxygen aim saturations 94-98% (if risk of CO2 retention then aim 88-92%)

Obtain 12 lead ECG

Obtain IV access

Bloods FBC, U&E, LFT, TropT, glucose, CRP, coagulation

CXR (but do not delay other treatment to obtain CXR)

Give aspirin 300mg stat if no contraindications and not given pre hospital

STEMI PATHWAY

TREAT AS STEMI

ACS PATHWAY

New ECG changes

(not meeting STEMI criteria)

Or on-going cardiac sounding

chest pain

Or positive initial TropT

NB. Consider other causes of

raised TropT (see note 1)

TREAT AS ACS

LOW RISK PATHWAY

Normal or non-diagnostic

ECG

Chest pain resolved

Initial TropT negative

(<17 male, <14 female)

Asbestosis

Asbestos pleural plaques

more Pleural Effusion

Unilateral usually requires either diagnostic tap, therapeutic aspiration or chest drainage (pH, protein, LDH, Cytology & Culture)

Bilateral usually due totransudate but not always

Acute pulmonary oedema Iv diuretic, oxygenation

Acute coronary syndrome Care bundle

Valvular heart disease Echo-make it happen

Most important slide If you are not sure about anything ask for help

If you are still not sure ask again

If you are getting an answer you are still unhappy with

ask someone more senior

Questions

ABCDE approach Airway

Causes of airway obstruction

CNS depression

blood

vomit

foreign body

direct trauma

infection

inflammation

laryngospasm

bronchospasm

blocked tracheostomy

ABCDE approach Airway

Recognition of airway obstruction

talking/not talking

difficulty breathing, distressed, choking

Short of breath, tired

see-saw respiratory pattern, accessory muscles

partial obstruction - noisy breathing

stridor, wheeze, gurgling

complete obstruction - silence

ABCDE approach Airway

Treatment of airway obstruction

high flow oxygen

airway opening

head tilt, chin lift, jaw thrust

simple adjuncts

oropharyngeal or nasal airway

advanced techniques

e.g. supraglottic airway device, tracheal tube

ABCDE approach Breathing

decreased respiratory drive

CNS depression

decreased respiratory effort muscle weakness

nerve damage

restrictive chest defect

pain from fractured ribs

lung disorders

pneumothorax

haemothorax

infection

acute exacerbation COPD

asthma

pulmonary embolus

pulmonary oedema

Causes of breathing problems

ABCDE approach Breathing

Recognition of breathing problems

Look Respiratory distress, accessory

muscles, cyanosis, respiratory rate, chest deformity, conscious level

Listen Noisy breathing, breath sounds

Feel Expansion, percussion

ABCDE approach Breathing

Treatment of breathing problems

airway opening

oxygen guided by pulse oximetry

treat underlying cause e.g. antibiotics for pneumonia

support breathing if inadequate e.g. ventilate with bag-mask