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Information ⬇

Author(s): David Sprigings and John B. Chambers

Assessment and initial management of the patient with acute breathlessness are summarized in Figure 10.1.

Priorities ⬆ ⬇

  1. Assess the airway, breathing and circulation (Chapter 1).
    • Attach ECG and oxygen saturation monitors. Give oxygen 35% by mask. Increase the inspired oxygen concentration if arterial oxygen saturation is <90%. Secure venous access.
    • Focused assessment is summarized in Table 10.1, and investigations needed urgently in Table 10.2.
  2. If upper airway obstruction is likely, because of abnormal voice, stridor (Box 10.2) or the clinical setting, sit the patient up and give high-flow oxygen. Call the resuscitation team and an ear, nose and throat (ENT) surgeon, in case tracheostomy is needed. Further assessment and management of upper airway obstruction is described in detail in Chapter 59.
  3. If there are signs of tension pneumothorax with impending cardiorespiratory arrest, insert a large-bore needle into the second intercostal space in the mid-clavicular line on the side with absent or reduced breath sounds. Further management of tension pneumothorax is described in Chapter 64.
  4. If cardiac tamponade is likely (risk factor for pericardial effusion, especially cancer, with raised jugular venous pressure and pulsus paradoxus (Box 10.2) palpable over the radial artery, see Chapter 54), obtain immediate echocardiography and perform pericardiocentesis if pericardial effusion with cardiac tamponade is confirmed (see Chapter 120 for the technique of pericardiocentesis).
  5. If there is respiratory failure (respiratory distress; respiratory rate <8 or >30 breaths/min; agitation or reduced conscious level; oxygen saturation <90% despite high-flow oxygen), call the resuscitation team and/or intensive care team. Further management of respiratory failure is described in Chapter 11.
  6. If there is wheeze, give nebulized salbutamol, 1 mg of nebulizer solution diluted in 2 mL of normal saline.
    • If the patient is hypoxic (oxygen saturation <90%), but does not have known chronic obstructive pulmonary disease (COPD), the nebulizer should be driven with oxygen: check the necessary flow rate on the nebulizer packaging.
    • If the patient has COPD with known or potential CO2 retention, use air as the driving gas.
  7. If there are signs of heart failure with pulmonary oedema (see Chapters 47 and 48):
    • Correct major arrhythmias.
    • Give furosemide 40 mg IV.
    • Provided systolic BP is >110 mmHg, give sublingual nitrate followed by IV nitrate infusion (e.g. isosorbide dinitrate 2 mg/h, increasing by 2 mg/h every 15–30 min) until breathlessness is relieved or systolic blood pressure falls below 100 mmHg or to a maximum of 10 mg/h, or buccal administration of nitrate (glyceryl trinitrate buccal tablet, 5 mg)
    • Consider non-invasive ventilation if there is respiratory distress (see Chapters 11 and 113).
    • Obtain urgent echocardiography (Table 48.2 and Chapter 114).

Further Management ⬆ ⬇

Review the ECG and chest X-ray arterial blood gas results. Check previous results (e.g. echocardiography, CT and pulmonary function tests).

The clinical assessment and results of first-line investigations should enable you to make a differential diagnosis and working diagnosis. Your differential diagnosis should be broad, and your working diagnosis must be repeatedly re-assessed in the light of the patient's progress.

Further management of specific disorders is given in Section 2.

Problems

Pneumonia or pulmonary oedema?

  • Differentiation can sometimes be difficult. Pulmonary oedema may be localized and when severe (alveolar) may produce an air-bronchogram. The radiological signs of pulmonary oedema are modified by the presence of lung disease.
  • The two diagnoses may co-exist: patients with heart failure are at increased risk of pneumonia; those with COPD are at increased risk of heart failure; and pneumonia may trigger acute atrial fibrillation and cause heart failure.
  • Pulmonary oedema is unlikely if there are no clinical or ECG features to suggest significant cardiac disease and the plasma BNP level is <100pg/mL (NT-proBNP <400pmol/L).
  • If in doubt, treat for both. If fever and a productive cough are absent, and the white cell count is <15×109/L or C-reactive protein <10 mg/L, give diuretic alone and assess the response. Repeat the chest X-ray the following day.
  • Arrange echocardiography to clarify the diagnosis if there are clinical or ECG abnormalities or the plasma BNP is >100pg/mL (NT-proBNP >400pmol/L).

Breathlessness with a raised jugular venous pressure

  • This combination may be seen in acute major pulmonary embolism, heart failure with biventricular involvement, chronic hypoxic lung disease complicated by cor pulmonale, and cardiac tamponade.
  • Obtain immediate echocardiography to clarify the diagnosis.

Breathlessness with clear lungs on chest X-ray

See Table 10.3.

Further Reading ⬆

Bohadana A, Izbicki G, Kraman SS. (2014) Fundamentals of lung auscultation N Engl J Med 370, 744–751. DOI: 10.1056/NEJMra1302901.

Dharmarajan K, Strait KM, Tinetti ME, et al. (2016) Treatment for multiple acute cardiopulmonary conditions in older adults hospitalized with pneumonia, chronic obstructive pulmonary disease, or heart failure. Journal of the American Geriatrics Society 64, 1574–1582. DOI: 10.1111/jgs.14303.

Francis GS, Felker GM, Tang WHW. (2016) A test in context: critical evaluation of natriuretic peptide testing in heart failure. J Am Coll Cardiol 67, 330–337.