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4 Shortness of breath Free
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Shortness of breath is the chief complaint for about 8% of 999 calls to the ambulance service, and is the third most common type of emergency call. It can also be an important symptom in patients with a wide range of conditions. Reference should therefore be made to other relevant articles—particularly that discussing chest pain. The conditions covered in this paper include asthma, chronic obstructive pulmonary disease, acute pulmonary oedema, and chest infections. The objectives for this paper are listed in box 1. Box 1 Article objectives
The common causes of shortness of breath are asthma, chronic obstructive pulmonary disease, and pulmonary oedema but there are many other conditions that can pose diagnostic problems (box 2). Box 2 Causes of breathlessnessVery common
Common
Rare
PRIMARY SURVEY POSITIVE PATIENTSRecognitionPatients with a life threatening respiratory emergency will present in either respiratory failure or respiratory distress. Patients with respiratory distress are still able to compensate for the effects of their illness, and urgent treatment may prevent their further deterioration. They present with signs and symptoms indicating increased work of breathing but findings suggesting systemic effects of hypoxia or hypercapnia will be limited or absent. Conversely, patients with respiratory failure may have limited evidence of increased work of breathing as they become too exhausted to compensate. The systemic effects of hypoxia and hypercapnia will be particularly evident in this group and immediate treatment will be required to prevent cardiac arrest. The key findings of primary survey positive patients with shortness of breath are presented in box 3. Box 3 Recognition of the primary survey positive patient with shortness of breathIncreased work of breathing
Systemic effects of inadequate respiration
PitfallCessation of wheeze in a patient with severe asthma may be misinterpreted as an improvement in the patients condition TipCyanosis may be detected in patients with increased skin pigmentation by examining the inside of the mouth and eyelids TreatmentIf it is not possible to obtain an airway, if the patient’s condition is deteriorating rapidly, or they show signs of significant respiratory failure (in particular failure to maintain Spo2 of 95% on high concentration oxygen) consider immediate transportation to a hospital with appropriate facilities. Important treatment points for primary survey positive patients are listed in box 4. Box 4 Treatment for primary survey positive patientsTreatment before transportation
Treatment during transportation In addition to the above, consider:
PRIMARY SURVEY NEGATIVE PATIENTS WITH NEED FOR HOSPITAL ATTENDANCEPrimary survey negative patients with the findings listed in box 5 who do not respond to prehospital treatment will require hospital admission. Box 5 Diagnostic criteria for primary survey negative patients requiring hospital admissionFindings (not reversed by initial treatment) suggesting need for hospital admission
SECONDARY SURVEYThe SOAPC system should be used to undertake a secondary survey (see article 2 of this series). In primary survey positive patients, a secondary survey may not be completed in the prehospital phase of treatment as the focus must be on treatment of life threatening problems. For primary survey negative patients requiring hospital care the secondary survey may be undertaken during transportation. For the remaining patient population a secondary survey may be undertaken at the point of contact and will contribute to the decision to admit, treat and refer, or treat and leave. TipIf the patient is unable to tolerate a nebuliser, administer 10–25 puffs of β2 agonist (for example, salbutamol 1.0 to 2.5 mg) from the patients’ own inhaler via a large volume spacer, which can be improvised if necessary (fig 1) Subjective assessmentConfirm that the chief complaint is shortness of breath. Remember that this may be a symptom of conditions affecting systems other than the chest (for example, hypovolaemia attributable to bleeding). Determine if this is a new problem or an exacerbation of a chronic condition. Ask what precipitated the problem and what, if anything, makes the patient feel more or less breathless. Ask about associated symptoms, such as chest pain, cough and sputum production, palpitations, fever and malaise, and leg pain or swelling. Has the patient been using inhalers or nebulisers more than normal? Have they recently sought other medical assistance? Inquire about previous similar episodes. If this has occurred before, find out what treatment led to its resolution. Has the patient been hospitalised previously for this condition? What is their general previous medical history? What medications are they currently taking, and why? Is there a family history of respiratory illness or heart disease? Finally, investigate the patient’s social circumstances. Is there evidence of self neglect? If the patient is not capable of caring for themselves, is there adequate carer support from family, friends, or health and social services? Does the patient smoke? Is there evidence of drug or alcohol misuse that may make the patient susceptible to infection? Objective examinationVital signsThe vital signs that should be recorded in a patient with shortness of breath are listed in box 6. Box 6 Vital signs for assessing shortness of breath
Social contextIn addition to the clinical assessment, it is important to consider the patient’s ability to care for themselves or whether suitable support mechanisms are available. If these are absent, can they be arranged? Can the patient perform the normal activities of daily living—feeding and washing themselves and using the toilet—either with or without support? The time of day and day of the week may also influence the decision about whether to admit or refer the patient, as this may dictate how quickly a patient could be seen by their own GP or reviewed by the emergency care practitioner. PitfallRrepeated “practice” attempts to measure maximum PEFR can worsen bronchospasm. Limit measurement to best of three forced exhalations General examinationLook for signs of the “unwell” patient (see article two in the series). A detailed examination of the respiratory system is mandatory for patients with shortness of breath. Remember, however, that myocardial infarction, acute coronary syndromes, and congestive cardiac failure can also result in respiratory distress, as may endocrine and neurological problems (for example Kussmaul’s and Cheyne-Stokes respiration in hyperglycaemia and raised intracranial pressure respectively). If a respiratory problem cannot be readily identified as the cause of the patient’s symptoms, undertake an examination of the other systems. TipElderly patients are likely to have multiple pathologies, so undertake a general systems examination TipAlhough shortness of breath can result from problems in many systems a useful clue is to note if there is any increase in effort of breathing. This invariably means the problem has a respiratory basis. For details of the respiratory examination, refer to boxes 3, 5, 6, and 7 of this article and article 2 of this series. Note if the patient has excessive production of sputum. What colour is this? Yellow, green, or brown sputum indicates a chest infection. White frothy sputum, which may also be tinged with pink, suggests pulmonary oedema. Look at the patient to determine their colour, and for signs of raised jugular venous pressure. Is the patient breathing through pursed lips, or using accessory muscles, perhaps suggesting COPD? Are there signs of CO2 retention (tremor of the hands, facial flushing, falling conscious level)? Palpate the trachea to check that it is in the midline. Examine the chest and observe chest expansion. Is this the same on both sides? Is there evidence of hyperinflation? Are scars present from surgery? Is there evidence of chest wall deformity? Feel the chest to confirm equality of movement, and check for chest wall crepitus and surgical emphysema. Is there evidence of chest wall tenderness or pain? Is any pain positional, or worsened on inspiration (as, for example, in pleurisy)? Feel for tactile vocal fremitus (see the journal web site http://www.emjonline.com/supplemental). Listen to the chest. Percuss the anterior and posterior chest wall bilaterally at the top, middle, and bottom of the back. Is the percussion note normal, dull, or hyper-resonant? Auscultate the chest at the same locations and in the axillae while the patient breaths in and out of an open mouth. Listen for the sounds of bronchial breathing, wheeze, or crackles. Listen for vocal resonance (see journal web site http://www.emjonline/supplemental) and pleural rubs. TipIf it is uncertain if a percussion note is dull or normal, compare with the result of percussing over the liver (lower ribs on the right). The percussion note will sound dull as the liver is a solid organ. TipTactile vocal fremitus and vocal resonance are increased in consolidation and decreased in pleural effusion and pneumothorax. If the adult patient complains of symptoms of a respiratory tract infection, undertake an ENT examination. Look in the mouth to examine for tonsullar and pharyngeal inflammation, and feel for enlargement of the lymph nodes in the neck. PitfallDo not attempt to examine the upper airway of a child with respiratory distress associated with stridor or drooling. These findings may be indicative of epiglottitis and attempts to examine the mouth and throat may provoke complete airway obstruction. In all patients with sudden onset of shortness of breath and in the absence of other findings strongly suggestive of a respiratory problem, undertake an examination of the cardiovascular system (see articles two and three of this series). The pertinent features of the respiratory examination are summarised in box 7. Box 7 Pertinent features of the respiratory examinationGeneral
Feel (palpate)
Look (inspect)
Listen (auscultate)
ANALYSIS (DIFFERENTIAL DIAGNOSIS)Diagnosis is often straightforward with a typical history and findings. For example, the patient presenting with wheeze and tachypnoea may state that they have asthma. The skill is in determining the severity of the condition. Few patients die as a result of the misdiagnosis of asthma but significant numbers die because professionals or patients under-estimate the severity of an episode. Differential diagnosis can also be very difficult, the classic situation being in distinguishing between an exacerbation of COPD and cardiogenic pulmonary oedema. This may be made simpler by the use of b-naturetic peptide (BNP) estimations. This has recently been made available as a near-patient test and may become increasingly common in the out of hospital setting. AsthmaTable 1 summarises the pointers in history and examination in patients with asthma that help to gauge the severity of an episode. Patients with severe or life threatening asthma need calm reassurance (even if the healthcare provider is panicking internally), early treatment with β2 agonists, oxygen, and immediate transfer to hospital. Patients with mild or moderate episodes who respond well to treatment may be suitable for home management with further inhaled β2 agonists, oral corticosteroids, and early review (tables 1 and 2).2 Table 1 Differential diagnosis of asthma Table 2 “Personal best” PEFR values with ranges for estimating severity of acute asthma episode COPDExacerbations of COPD are common. These can be triggered by a number of factors but a viral infection is the most frequent. Diagnosis is often simple but it is the assessment of the severity of the condition that needs skill. The main differential diagnosis is of cardiogenic pulmonary oedema (LVF). A pneumothorax is an uncommon reason for a severe sudden exacerbation of COPD. Knowledge of the patient’s normal pulmonary function is important. Some patients with COPD have a “normal” Po2 that would indicate severe respiratory failure in a normal person. Signs of exhaustion, inability to expectorate, or CO2 retention are the main worrying features indicating a severe episode. Oxygen treatment in these patients should be titrated against the SPo2 (controlled oxygen therapy—see the North-West Oxygen Group guidelines).1 If the episode is not severe and the patient has adequate home support, then hospital admission may be avoided (table 3).3 Table 3 Differential diagnosis of chronic obstructive pulmonary disease (COPD) Acute cardiogenic pulmonary oedemaThe onset is often sudden and severe. The patient is older and usually has a history of ischaemic heart disease although this may be the first indication of heart problems. Acute MI is often a precipitating factor. Severe shortness of breath, white frothy sputum, tachypnoea, and tachycardia are common. Such patients need to be transported to hospital, sitting upright if possible. Immediate treatment consists of buccal nitrates (providing the blood pressure is not low), oxygen, and intravenous opioids (table 4). Table 4 Differential diagnosis of acute pulmonary oedema (left ventricular failure/LVF) PneumoniaFever, malaise, and purulent sputum suggest a diagnosis of pneumonia. The criteria for home treatment varies from country to country (table 5).4 Table 5 Differential diagnosis of shortness of breath with fever and malaise (pneumonia) CONDITIONS FOR EXCLUSION IF HOSPITAL ATTENDANCE IS NOT CONSIDERED APPROPRIATEBox 5 lists the key findings that indicate the need for immediate hospital admission in primary survey negative patients. Table 6 describes additional findings determined from the secondary survey that will suggest the need for hospital admission. In asthma or COPD, failure to respond to the initial dose of a β2 agonist (for example, nebulised salbutamol) is also an indication for considering hospitalisation, as is a history of a previous near fatal attack—regardless of the severity of the current episode. All patients with a first episode of pulmonary oedema or an acute exacerbation of a chronic problem should be admitted to hospital for further investigation and treatment. Table 6 Findings from secondary survey suggesting need for hospital admission PneumothoraxSpontaneous pneumothorax is most common in tall, thin, fit young men (see table 6). It is an uncommon complication of asthma and COPD. There are some rarer causes but these will be very uncommon in the community setting. If a pneumothorax is suspected, the patient will need to be referred to hospital for a radiograph and further evaluation. Pulmonary embolismHalf of all patients suffering for pulmonary embolism will develop this condition while in hospital or long term care. The remainder will have an unknown aetiology or will have been exposed to a known risk factor (see table 6). If a pulmonary embolism is suspected the patient will require urgent transfer to hospital for possible heparinisation or thrombolysis.5 TREATMENT AND DISPOSAL (PLAN)The initial out of hospital treatment of each of the four key conditions is given in table 7 and boxes 8 to 10. Interventions recommended in the JRCALC guidelines for paramedic use are asterisked.6 Table 7 Treatment of asthma2 PitfallTension pneumothorax is a rare complication of asthma. Monitor for its signs and perform needle thoracocentesis (decompression) if these are present TipCheck the inhaler technique of patients left at home.7 PitfallTension pneumothorax is a rare complication of COPD. Monitor for its signs and perform needle thoracocentesis (decompression) if these are present PitfallRule out acute MI: if present consider opioids, nitrates, aspirin, heparin, and thrombolysis according to relevant guidelines Box 8 Treatment of COPD3
Box 9 Treatment of acute pulmonary oedemaAll patients with an acute exacerbation of pulmonary oedema require hospitalisation
Box 10 Treatment of pneumonia4
DISPOSITION FLOW CHARTFigure 3 describes the decision making process for patient disposition. FOLLOW UPPatients with an acute exacerbation of the conditions discussed in this paper but not requiring hospital admission should be advised to request further assistance if their condition deteriorates once the carer has left. Reassessment of the need for hospital admission is then mandatory. All patients provided with home care should be referred for an appointment with their general practitioner within a suitable time frame for further assessment. This will include consideration of the patient’s ongoing condition, their ability to use inhalers correctly, measurement of their respiratory function (FEV1), and lifestyle management advice (for example, smoking cessation, weight control, exercise). AcknowledgmentsThanks to Jim Wardrope, Peter Driscoll, and Colville Laird whose feedback resulted in valuable improvements to earlier drafts of this paper. Contributions Malcolm Woollard wrote the first draft of the paper. Malcolm Woollard and Ian Greaves edited all subsequent drafts. REFERENCES
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Supplementary materials
Read the full text or download the PDF:Log in using your username and passwordWhat are signs that a patient is having difficulty breathing?A bluish color seen around the mouth, on the inside of the lips, or on the fingernails may happen when a person is not getting as much oxygen as needed. The color of the skin may also appear pale or gray. Grunting. A grunting sound can be heard each time the person exhales.
What are 3 possible signs of difficulty breathing?Rapid breathing, an increased heart rate, and gasping for breath are three common signs of breathing difficulties. How do you know if shortness of breath is serious? If you're short of breath at rest, or can't get enough air despite deep breaths, you should see a doctor.
Which findings would indicate that the patient's breathing is adequate?SIGNS OF ADEQUATE VENTILATION: In most patients, your assessment of ventilation will be based on observing their respiratory rate (normal 12 to 20) and listening for clear breathing sounds in the left and right chest. Auditory confirmation of breathing sounds is the strongest sign of adequate ventilation.
What assessment finding would be present in a client in respiratory distress?Patients in respiratory distress may have an anxious expression, pursed lips, and/or nasal flaring. Asymmetrical chest expansion may indicate conditions such as pneumothorax, rib fracture, severe pneumonia, or atelectasis. With hypoxemia, cyanosis of the extremities or around the mouth may be noted.
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