Breathlessness in

the ED

Caitlin Everson
Clinical Fellow AED
 Main Respiratory
Symptoms
 Dyspnoea
 Cough
 Chest Pain
 Wheeze
 Haemoptysis
 Systemic symptoms
 PMH
 Known conditions
 Previous exacerbation
 Required intubation/NIV
 Drugs
 Regular meds
 Home O2 or nebulisers?
 Recent steroids?

 Any drugs that can cause respiratory side effects

 ALLERGIES
 Social
 Smoking – tobacco, cannabis

 Living situation – able to cope, steroids, shopping etc

 Occupations and hobbies

 Travel – long flights, high risk areas

 Standby Phone
 Acute difficulty in breathing
 Sick patient
 ETA 5 mins
 Big Tips
 Don’t always blame the lungs
 As always start with an ABCDE approach
 Oxygen
 Hypoxia kills before hypercapnia – so give Oxygen
 Venturi mask
 If giving oxygen consider doing an ABG
 Be careful before labelling things as chronic – treat
any significant acidosis as new
 Fluids
 Acute pulmonary oedema may be the cause
 Sepsis and metabolic derangement can cause
breathlessness and need plenty of fluids to stabilise
the patient
 Overload can occur even in pts with previously normal
LV function
 Just keep reviewing them!
 When to call ITU
 Tiring
 Not oxygenating properly
 Not ventilating properly

…despite aggressive treatment

 Causes
 Pulmonary
 Cardiovascular
 Traumatic
 Abdominal
 Psychogenic
 Metabolic
 Neuromuscular
 Investigations
 Pulse Ox
 ABG
 CXR
 ECG
 Acute Asthma
exacerbation of
COPD

Pneumothorax
PE

Lung Cancer
 Definition
 A sustained worsening of patient’s symptoms
 Which is beyond day to day variation
 Acute in onset
 Features
 Worsening cough
 SOB
 Increased sputum or change in colour
 Wheezy
 May have areas of reduced air entry
 ABG – hypoxia +/- hypercapnia
 Treatment
 Controlled O2
 Nebs – salbutamol and ipratropium bromide
 Prednisolone 30mg
 Abx
 NIV
 Exacerbation of COPD with persistent respiratory
acidosis
 In whom medical treatment is unsuccessful
 They need BIPAP
 Clear escalation plan needed
 MRC Dyspnoea Scale
1. Not troubled by breathlessness except on strenuous
exercise

2. SOB when hurrying or walking up a slight hill

3. Walks slower than contemporaries on level due to

breathlessness or has to stop when walking at own
pace

4. Stops for breath after ~100m or couple of mins on flat

5. House-bound due to breathlessness

 Acute
exacerbation of Asthma
COPD

PE Pneumothorax

Lung Cancer
 Moderate Asthma
 Increasing symptoms
 PEF >50-75% best or predicted
 No features of acute severe asthma
 Acute Severe
 PEF 33-50% best or predicted
 Respiratory rate ≥25/min
 Heart rate ≥110/min
 Inability to complete sentences in one breath
 Life threatening
Asthma
 PEF <33% best or predicted
 SpO2 <92%
 PaO2 <8 kPa
 Normal PaCO2 (4.6-6.0 kPa)
 Silent chest
 Cyanosis
 Poor respiratory effort
 Arrhythmia
 Exhaustion, altered conscious level
 Hypotension
 When to do a CXR?
 Suspected pneumothorax
 Suspected consolidation
 Life threatening asthma
 Failure to respond to treatment
 Requirement for ventilation
 Treatment in ED
 Salbutamol 5mg Neb and Ipratropium bromide
500mcg Neb
 Prednisolone 40-50mg PO
 Magnesium Sulphate 1.2-2g IV over 20 mins
 Aminophylline 5mg/kg IV over 20mins followed by
500-700mcg/kg/hr infusion
 Acute Asthma
exacerbation of
COPD

PE
Pneumothorax

Lung Cancer
 Clinical Features
 Dyspnoea (70%)  Haemoptysis

 Tachypnoea  Leg pain

 Pleuritic chest pain  Clinically evident DVT (10%)

 Apprehension

 Tachycardia (>100)

 Cough
 Risk Factors
 Cancer
 Recent Immobility
 COCP
 Smoking
 Obesity
 Late pregnancy
CXR
 ECG
 Normal
 Sinus tachy
 RBBB
 S1 Q3 T3 – evidence of right heart strain (10%)
Wells’ criteria
 PERC criteria
 Age >50
 HR >100
 Sats <95%
 Unilateral leg swelling
 Haemoptysis
 Recent surgery or trauma (with GA)
 Prior PE or DVT
 Hormone use
 Gold standard?
 CTPA
 Treatment
 Apixaban 10mg BD for 7 days then 5mg BD
 Thrombolysis if unstable
 Acute
exacerbation of
Asthma
COPD

PE Pneumothorax

Lung Cancer
 Definitions
 Collection of gas in the pleural space
 Primary = no underlying lung disease
 Secondary = underlying lung disease e.g COPD,
malignancy
 Acute
exacerbation of
Asthma
COPD

PE Pneumothorax

Lung Cancer
 Lung Cancer
 Most common cancer worldwide

 95% carcinoma of bronchus

 5% alveolar carcinomas or benign

 Majority smoking related (90%)

 Can get secondaries from other cancers

 Prognosis is extremely poor

 Squamous Cell
Carcinoma
 Usually present as obstructive lesions in bronchus
leading to infection
 Occassionally cavitates (10% on presentation)
 Local spread common
 Metastasis late but frequent
 Causes hypercalcaemia
 Adenocarcinomas
 Arises from mucous cells in the bronchial epithelium
 Commonly invades mediastinal lymph nodes and the pleura
 Spreads to brain and bone
 Don’t usually cavitate
 Cause excessive mucous secretions
 Least likely to be smoking related
 Most likely to cause pleural effusions
 Can get confused with mesotheliomas
 Large cell carcinomas
 Less differentiated
 Metastasize early
 Prognosis poor
 Bronchoalveolar cell
carcinoma
 Very rare
 Present as a single nodule or multiple small nodules
 Occasionally appear as consolidation on CXR
 Causes excessive production of white sputum
 Small Cell Carcinomas
 Arise from endocrine cells - APUD cells
 Secrete various polypeptides
 Leads to various presentations such as Addisons or
Cushing’s
 Spreads early
 Almost always inoperable at presentation
 Prognosis poor
 Classifications
 Small cell carcinomas
 Limited – confined to 1 lung or hemithorax
 Extensive – distant metastasis

 Non small cell  use TMN staging

 Treatment – non small
cell
 Stage 1 – operable (5 yr survival after surgery 70%)
 Stage 2 – operable (5 yr survival drops to 40%)
 Stage 2A – most surgeons don’t want to operate (25%
survival) – adjunctive chemo post surgery can improve
survival by 5%
 Stage 4 – chemo only

 Radical radiotherapy (Any stage) – 5 yr survival 20%

 Treatment – small cell
 No curative treatment
 Most have metastasized by presentation
 Palliative chemo
 Limited  Life expentancy increases from 3 months
to 1 yr with chemo
 Extensive  life expenctancy increases from 1 month
to 8 months with chemo
 90% don’t respond to chemo
 Mesothelioma
 Asbestos related – even light exposure
 Starts as pleural plaques and gradually grow around
the whole lung lining
 Presents with pleural effusions and progressive
dyspnoea
 Can have chest wall pain and ascites
 Median survival 2 years
 No treatment
Cases
 Case 1
 25M
 1/52 hx - dry cough but now started to produce a little
sputum.
 Myalgia, tiredness, headaches
 2/7 hx of diarrhoea
 37.9°C, HR 91, BP 128/75, RR 22, SaO2 98% on air.
 O/E - audible crackles on the right side of his chest.
 Investigations
 CXR - right upper lobe consolidation.
 AMTS is 10/10
 Urea to be 6.3 mmol/l

 What is the CURB score?

 What is the likely organism?
 CURB-65
 Confusion – AMTS <8
 Urea >7
 RR >30
 BP Systolic <90 Diastolic <60
 Age >65
 Mycoplasma
Pneumoniae
 Buzz words
 Initially dry cough  little production of sputum

 Treatment – Macrolides or tetracycline for 10-14 days

 Case 2
 30F
 Presents with an Acute exacerbation of her asthma
 HR 115, RR 28, Sats 82% RA
 She is tired and her respiratory effort is poor and her
chest is silent on auscultation.

 How would you classify this asthma?

 Case 3
 40M
 Couple days hx of dry cough + fever
 Non-productive
 Today he has also had several episodes of diarrhoea
 Developed bilateral pleuritic chest pain
 SOB, most notably on exertion.
 He works as a Jacuzzi and whirlpool installer and smokes
15 cigarettes per day.
 Legioneres Disease
 Buzz words
 Works with hottubs
 Recently been to all inclusive requiring air conditioning

 Organism  Legionella pneumophilia

 Treatment  macrolide or tetracycline or quinolone
 Case 4
 32M
 Several recent episodes of large quantities of haemoptysis
 Extremely fatigued
 Worsening nausea.
 Experiencing intermittent chest pain
 Urine has ‘appeared dark in colour’.
 No PMH
 Smokes 15 cigarettes per day.
 O/E
 Pale
 Inspiratory crackles at both bases
 BP 175/94 mmHg.
 Urinalysis reveals proteinuria and microscopic
haematuria
 Bloods
 Hb 8.4 g/dl
 MCV 69 fl
 WCC 21.5 x 109/l
 Neutrophils 17.2 x 109/l
 Na 134 mmol/l
 K 4.2 mmol/l
 Creat 232 micromol/l
 Urea 12.8 mmol/l
 Good Pastures
 Buzz words
 Renal + lung involvement

 Investigation – renal biopsy taken and examined for

presence of anti-glomerular basement membrane
antibodies
 Case 5
 23M
 SOB and right sided pleuritic chest pain
 No PMH
 No regular medications
 NKDA
 O/E
 Reduced air entry over his right lung
 Hyper-resonant percussion note
CXR
 Pneumothorax
 Buzz words
 Hyper resonant percussion
 Tale male asthmatic
 Cannabis smoker

 Treatment (in this case) – pleural aspiration

 Case 6
 64F
 1/52 Hx of worsening cough and breathlessness
 She has deteriorated over the past 24 hours
 Now developed right-sided chest pain.
CXR
 She is mildly confused, with an AMTS of 7/10, her
respiratory rate is 32/minute, her blood pressure is
100/50 mmHg and her blood urea is 7.7 mmol/l.
 What is her CURB-65 score?
 Community acquired
pneumonia
 Most likely organism  streptococcus pneumoniae

 Treatment depending on CURB score

 Abx – Amoxicillin 500mg TDS if PO (1g IV) +/-
clarithromycin
 Case 7
 24F
 Severe chest pain
 Worse on inspiration
 Has had a couple of episodes of haemoptysis
 She takes the combined oral contraceptive pill
 Recently been fairly sedentary due to a broken ankle.
 Pulmonary Embolus
 Buzz words
 Risk factors!
 Signs of DVT

 Gold standard Ix – CTPA

 Treatment – Apixaban or LMWH
 Case 8
 78M
 Been seen by his GP with a recent onset of a cough
and a temperature
 He has been a heavy smoker for many years.
 He was diagnosed with a community-acquired
pneumonia and commenced on antibiotics.
 He has been brought in by ambulance with a couple of
episodes of haemoptysis.
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
 ED Management
 SECURE AIRWAY
 Bloods for FBC, clotting, U&Es, LFTs
 X-match if there has been significant haemorrhage
 ABG
 O2 sats should be monitored
 CXR looking for underlying causes
 ECG
 Sputum samples to exclude TB/ infection
 Monitor fluid balance – catheterize 
 Haemoptysis +
 URT  epistaxis, sinusitis
 Glomerulonephritis
 Saddle shape nose deformity

 Diagnosis??
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
 Wegener’s
Granulomatosis
 Haemoptysis +
 Past history of TB
 CXR  rounded opacity
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
Aspergilloma
 Haemoptysis +
 Dyspnoea
 AF
 Malar flush on cheeks
 Mid-diastolic murmur
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
Mitral Stenosis
 Haemoptysis +
 Long history of cough
 Daily purulent sputum production
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
Bronchiectasis
 Haemoptysis +
 Acute history of purulent cough
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
LRTI
 Haemoptysis +
 History of smoking
 Weight loss
 Anorexia
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
Lung cancer
 Haemoptysis +
 Fever
 Night sweats
 Anorexia
 Weight loss

 ?foreign travel
 ?born in high risk area
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
TB
 Haemoptysis +
 Dyspnoea
 Bibasal crackles
 S3 (Heart sound)
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
Pulmonary oedema
 Haemoptysis +
 Pleuritic chest pain
 Tachycardia
 Tachypnoea
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
PE
 Haemoptysis +
 Glomerulonephritis
 Systemically unwell – fever, nausea
Causes of Haemoptysis
 Infection (includes TB,  Trauma
pneumonia, lung abscess)
 Iatrogenic (e.g. warfarin,
 Lung cancer heparin)

 Bronchiectasis  Wegener’s granulomatosis

 Pulmonary embolus  Goodpasture’s syndrome

 Ruptured aortic aneurysm  Emphysema

 Pulmonary oedema
Goodpasture’s
syndrome
Case 9
 Pulmonary Oedema
 Buzz words
 Unable to lie flat
 Cardiac history (IHD or Valvular disease)

 CXR changes
 Cardiomegaly
 Increased interstitial vascular markings
 Upper lobe diversion

 Treatment – diuretics and nitrates

 Finally
 Stay calm
 Patient will be anxious which will make their SOB
worse!
 If you stay calm they will relax a bit and their
breathing may improve
 ABCDE
 Stabilise the patient and think about the rest then!
Questions?