BREATHLESSNESS ABSTRACT INTRODUCTION Dyspnoea, Also

Home , Bronchospasm, Shortness of breath

EMERGENCY MEDICINE – WHAT THE FAMILY PHYSICIAN CAN TREAT

UNIT NO. 4 BREATHLESSNESS In one study of 85 patients presenting to a pulmonary unit Psychiatric conditions appropriate context of the history, physical examination, and ischaemia. Serial measurements of cardiac biomarkers are inhaler (MDI). In severe asthma, patients should be transferred breathlessness. In such cases, it is prudent to start therapies for with a complaint of chronic dyspnoea, the initial impression Psychogenic causes for acute dyspnoea is a diagnosis of the consideration of dierential diagnosis. Random testing necessary as initial results can often be normal. to ED for further treatment with nebulised ipratropium multiple conditions in the initial resuscitative phase. For Dr Pothiawala Sohil of the aetiology of dyspnoea based upon the patient history exclusion, and organic causes must be ruled out rst before without a clear dierential diagnosis will delay appropriate bromide, intravenous magnesium, ketamine, IM adrenaline, example, for a patient with a past medical history of COPD and alone was correct in only 66 percent of cases.4 us, a considering this diagnosis (e.g., panic attack).5 management. e use of dyspnoea biomarker panels does not Brain natriuretic peptide (BNP) intubation, and inhalational anaesthesia as needed. congestive cardiac failure, the initial management of sudden systematic approach, comprising of adequate history and appear to improve accuracy beyond clinical assessment and is is used to diagnose heart failure, but it can also be elevated onset of dyspnoea may include therapies directed at both these ABSTRACT diagnostic studies, and provide recommendations for initial physical examination, followed by appropriate investigations focused testing.6, 7 in uid overload secondary to renal failure. BNP testing is not COPD exacerbation conditions. After initial stabilisation, the nal disposition of the Breathlessness, also known as dyspnoea, is a common management and disposition. presenting complaint in the outpatient family physician clinic. is necessary. PHYSICAL EXAMINATION helpful when used indiscriminately in patients with acute Patients with mild exacerbation are treated with nebulised patient depends on your consideration of the dierential It is most commonly caused by respiratory and cardiac Blood tests dyspnea.10, 11 salbutamol, ipratropium and steroids. Antibiotics are indicated diagnosis. Unstable patients should be transported to the disorders, but there are lots of other important aetiologies Signs that suggest severe respiratory distress include e initial evaluation usually includes measurement of if there is evidence of an infective process suggested by fever, emergency department for further evaluation and treatment. that need to be considered. The initial goal of assessment is to EPIDEMIOLOGY HISTORY tachypnoea/bradypnoea, retractions, use of accessory muscles, haemoglobin (to exclude anaemia as a cause of dyspnoea), D-Dimer increased sputum production, or purulent sputum. Patients Patients who are stable should be discharged with appropriate determine the severity of the dyspnoea, considering the need inability to speak in full sentences, inability to lie supine or in for oxygen therapy and intubation. Unstable patients usually A chief complaint of dyspnoea or shortness of breath made up blood glucose (to rule out Kussmaul’s breathing secondary to Patients at low risk for PE according to a validated scoring with moderate to severe respiratory distress should be sent to medications and advised to return back if their condition a tripod position, diaphoresis, agitation or altered mental present with abnormal vital signs, hypoxia, diaphoresis, and/or 3.5 percent of the more than 115 million visits to United States e history forms a critical component in the evaluation of the diabetic ketoacidosis), urea, creatinine and electrolytes. system (Wells criteria for PE, PERC rule) and a negative ED for further management, which can include non-invasive persists or worsens. status, and cyanosis. altered mental states, and require urgent management. EDs in 2003. Other dyspnoea-related chief complaints (cough, dyspnoeic patient, but can be dicult to obtain when the d-dimer can be ruled out for PE without further testing. It ventilation (BiPAP) or endotracheal intubation. Ongoing care depends on the differential diagnosis established chest discomfort) comprised 7.6 percent.2 patient has diculty speaking. Relevant history can be Chest X-ray cannot be used as a rule-out test in patients with moderate to by an adequate history and physical examination, and obtained from the patient, paramedics, family, and caretakers. Retractions occur with airway obstruction (e.g., asthma, e chest radiograph may provide clues to the cause of high pre-test probability of PE. Pneumonia CONCLUSION investigations, if available, can aid definitive diagnosis. The COPD, foreign body) and can be seen in the suprasternal, dysnoea. Patients who are low risk using the CURB-65 score should be family physicians must be equipped to initiate appropriate According to one prospective observational study, the most Present history intercostal, and subcostal areas. ey are an ominous sign e family physicians must be equipped to perform an initial therapy, conduct continuous monitoring and stabilise an common diagnoses among elderly patients presenting to an Arterial and venous blood gas commenced on appropriate antibiotic therapy as per the local suggesting extreme respiratory distress. e use of accessory acutely dyspnoeic patient before determining the final ED with a complaint of acute shortness of breath and Enquire regarding the symptoms, duration, severity, onset - Signs of Acute heart failure are cardiomegaly, cephalisation of e role of the arterial blood gas (ABG) in the diagnosis and antibiotic guidelines and discharged with follow-up within 5-7 assessment, initiate appropriate therapy and stabilise an acutely muscles to breathe suggests fatigue of the respiratory muscles disposition of the patient. manifesting signs of respiratory distress (e.g., respiratory rate whether it is sudden or gradual. Acute dyspnoea following a blood vessels, interstitial oedema ( "Kerley B" lines) and treatment of the acutely dyspnoeic patient is limited. Venous days for re-assessment. Patients with moderate to high risk dyspnoeic patient before determining the disposition of the and a potential for respiratory failure. Diaphoresis reects >25, SpO <93%) are decompensated heart failure, meal or medication suggests an allergic reaction; a new pulmonary vascular congestion. Pleural eusion may be blood gas can be used as an alternate to determine the acid-base should be referred to the hospital for admission and further patient, either discharging home or referring to the emergency Keywords: 2 productive cough suggests chest infection; viral infection or extreme sympathetic stimulation associated with severity of department for further management. pneumonia, chronic obstructive pulmonary disease, present. Around 20 percent of patients admitted with acute status. e PaCO2 levels are low in a breathless patient due to management. In severe pneumonia, 3rd-generation Breathlessness, Dyspnoea, Family Physician, Differential 8 3 allergen exposure can trigger asthma; recent surgery, disease process (myocardial infarction, severe asthma, heart failure may have a non-diagnostic CXR. hyperventilation. A normal or elevated CO in a breathless cephalosporin (ceftriaxone) with a macrolide (azithromycin) is Diagnosis, Management pulmonary embolism, and asthma. 2 immobilisation or long travel time increases the risk for pulmonary oedema). Altered mental status suggests severe patient suggests respiratory failure. the rst-line treatment. In patients with penicillin allergy, a REFERENCES 1. Parshall MB, Schwartzstein RM, Adams L, et al. An official American pulmonary embolism (PE); and trauma may cause hypoxia or hypercarbia, but may also be caused by underlying - In ltrates on CXR are considered the “gold standard” for uoroquinolone should be used. SFP2015; 41(3): 24-29 PATHOPHYSIOLOGY Thoracic Society statement: update on the mechanisms, assessment, pneumothorax or pulmonary contusion. Noncompliance with pathology (e.g., hypoglycaemia, sepsis, poisoning). Cyanosis is diagnosing pneumonia. But X-rays obtained early in the CT orax and management of dyspnea. Am J Respir Crit Care Med. 2012 Feb a late sign and indicates severe hypoxia. 9 e respiratory system is designed to maintain homeostasis medications or increased uid intake may lead to acute clinical course of illness may be non-diagnostic. Also, the A multi-detector computed tomography (MDCT) scan of the Acute Pulmonary Oedema 15;185(4):43552. INTRODUCTION with respect to gas exchange and acid-base status. decompensated heart failure. appearance of the CXR (lobar versus diuse) does not thorax is not indicated in the initial evaluation, but can aid Intravenous frusemide along with sublingual nitroglycerine 2. American College of Emergency Physicians. Vital signs include temperature, heart rate, respiratory rate www.acep.org/webportal/Newsroom/NewsMediaResources/Statistics Derangements in oxygenation, ventilation and acidaemia can accurately predict the aetiology of the pneumonia (typical diagnosis of PE, malignancy, etc. MDCT entails complications tablets/spray should be commenced in the clinic. ey should Dyspnoea, also known as shortness of breath, is one of the Past history and pulse oximetry. Patients with serious underlying disease versus atypical). like contrast-induced nephropathy, contrast allergy, radiation, then be transferred to the nearest ED for further management. Data/default.htm (Accessed on February 04, 2006). lead to dyspnoea. e development of dyspnoea is a complex 3. Ray P, Birolleau S, Lefort Y, et al. Acute respiratory failure in the e patient may have pre-existing illness like asthma, COPD, may have a fast, normal, or slow respiratory rate. e extremes and hence must be used judiciously. most common presentations in the emergency department or a phenomenon generally involving stimulation of a variety of elderly: etiology, emergency diagnosis and prognosis. Crit Care. indicate the severity of the underlying disease process. Pulse primary care setting. e dierential diagnosis ranges from mechanoreceptors throughout the upper airway, lungs, and or ischaemic heart disease, and the dyspnoea can be a result of - A pneumothorax is usually visible on CXR as an area with Pneumothorax 2006;10(3):R82. oximetry is an indicator of arterial oxygenation. It may be simple medical conditions to life-threatening causes, and chest wall, and chemoreceptors at the carotid sinus and the exacerbation of a preexisting illness. e medical records and absence of lung markings. Peak ow and pulmonary function tests (PFTs) For a patient showing signs of tension pneumothorax, needle 4. Pratter MR, Curley FJ, Dubois J, Irwin RS. Cause and evaluation of inaccurate in the setting of hypothermia, shock, carbon establishing a de nitive diagnosis can be challenging. medulla. Respiratory system dyspnoea is related to disorders of medication list can provide important diagnostic clues. e peak expiratory ow rate (PEFR) is useful in determining thoracentesis should be urgently performed in the 2nd chronic dyspnea in a pulmonary disease clinic. Arch Intern Med. 1989 monoxide poisoning, methemoglobinaemia, etc. Oct;149(10):2277-82. the respiratory centre in the brainstem, the respiratory - Hyperinated lung elds and a attened diaphragm are the severity of asthma and response to treatment. intercostal space in the mid-clavicular line on the aected side. Dyspnoea is de ned as the subjective experience of breathing Prior intubation suggestive of air trapping that occurs with COPD or asthma. With the cannula in-situ, the patient can then be transferred by 5. Bass C. Chest pain and breathlessness: relationship to psychiatric muscles, and the lung and alveoli. e cardiovascular system illness. Am J Med. 1992 Jan 24;92(1A):12S-17S. Patients with a history of prior endotracheal intubation have a A thorough systemic examination is an essential part of the Unilateral air trapping suggests obstruction by a foreign body the paramedics to the ED for de nitive management with discomfort that is comprised of qualitatively distinct sensations dyspnoea occurs as a result of cardiac diseases (e.g., acute 6. Singer AJ, Thode HC Jr, Green GB, et al. The incremental benefit of evalution process, and should include inspection, palpation, MANAGEMENT that vary in intensity. e experience derives from interactions myocardial ischaemia, systolic or diastolic heart failure, higher severity risk and the need for subsequent intubation. or mucus plugging. chest-tube insertion. Patients with simple pneumothorax a shortness-of-breath biomarker panel in emergency department percussion and auscultation of the cardio-pulmonary, among multiple physiological, psychological, social, and valvular disorders, pericardial diseases, etc.) and anaemia. A should be commenced on oxygen and referred to the ED for patients with dyspnea. Acad Emerg Med. 2009 Jun;16(6):488-94. Associated Symptoms abdominal and neurological systems. A quick initial assessment will aid the doctor in determining if environmental factors, and may induce secondary combination of these underlying mechanisms can also Electrocardiogram (ECG) further management. 7. Gruson D, Thys F, Ketelslegers JM, et al. Multimarker panel in 1 the patient is stable or unstable. e management is dependent patients admitted to emergency department: a comparison with physiological and behavioral responses. co-exist. Always check for associated symptoms like chest pain (acute coronary syndrome, pneumothorax, PE), fever (infection), During examination of the respiratory system, the following An ECG with ST segment and T-wave changes constitutes on his/her presentation and possible diagnosis, but the initial Pulmonary Embolism reference methods. Clin Biochem. 2009 Feb;42(3):185-8. 8. Collins SP, Lindsell CJ, Storrow AB, et al. Prevalence of negative trauma (pneumothorax, haemothorax), paroxysmal nocturnal abnormal breath sounds should be identi ed: strong evidence of cardiac ischaemia. However, clinicians must treatment includes administration of supplemental oxygen A patient suspected to have PE should be risk strati ed using the A patient with acute dyspnoea presents challenges in diagnosis Evaluation of Dyspnoea chest radiography results in the emergency department patient with using various oxygen delivery devices. You need to be careful and subsequent management. e clinician must consider a Acute dyspnoea is de ned as breathing diculty that arises dyspnoea (heart failure), and haemoptysis (tuberculosis, remember that the initial ECG is normal in approximately 20 Wells criteria for PE or PERC rule for PE. Patients who are low decompensated heart failure. Ann Emerg Med. 2006 Jan;47(1):13-8. • Stridor occurs due to upper airway obstruction. Inspiratory using oxygen in patients with COPD with type 2 respiratory long list of dierential diagnoses while providing appropriate over the course of minutes to hours. Consideration needs to be malignancy, PE). e presence of cough and quality of percent of patients subsequently diagnosed with a myocardial risk and PERC positive should have a D-dimer. If the D-dimer 9. Basi SK, Marrie TJ, Huang JQ, Majumdar SR. Patients admitted to stridor suggests obstruction above the vocal cords (e.g., failure (hypercapnoea) as it may depress their respiratory drive. initial treatment for a potentially life-threatening illness. In this given to relatively few but life-threatening conditions. ese sputum should be enquired as purulent sputum suggests infarction, and only 33 percent of initial ECGs are diagnostic. is negative, PE is ruled out. e chest X-ray is usually normal, hospital with suspected pneumonia and normal chest radiographs: foreign body, epiglottitis, angioedema). Aim to maintain oxygen saturation of around 94 percent. epidemiology, microbiology, and outcomes. Am J Med. 2004 Sep article, we shall review the pathophysiology of dyspnoea, entities typically have associated symptoms and signs that pneumonia, pink frothy sputum suggests heart failure. e ECG may also reveal signs of pulmonary embolism (right but Hampton’s hump or Westermark sign are rare and consideration of the dierential diagnosis, and management. Similarly, dry cough is a non-speci c symptom, and can be heart strain) and pericardial eusion (low-voltage complexes, Establish intravenous access and start administration of uids if diagnostic of PE. Patients who are intermediate or high risk, or 1;117(5):305-11. provide clues to the appropriate diagnosis, e.g., substernal 10. Schneider HG, Lam L, Lokuge A, et al. B-type natriuretic peptide associated with asthma, heart failure, respiratory infection, or • Wheezing occurs as a result of bronchoconstriction and can electrical alternans). indicated. Consider the use of oral or nasopharyngeal airway in who have a positive D-dimer, should have advanced imaging chest pain with cardiac ischaemia; fever, cough, and sputum testing, clinical outcomes, and health services use in emergency be heard in patients with asthma, COPD, anaphylaxis, patients who are unable to maintain their airway due to is topic review will provide a dierential diagnosis of the with respiratory infections; urticaria with anaphylaxis; and PE. like CT pulmonary angiogram. Treatment is largely supportive, department patients with dyspnea: a randomized trial. Ann Intern foreign body obstruction, acute heart failure, or a tumour. depressed levels of consciousness. Intubation may be needed if life-threatening and common causes of dyspnoea in the adult, wheezing with acute bronchospasm. However, dyspnoea may Bedside Ultrasound with oxygen therapy. Patients who are hypotensive due to Med. 2009 Mar 17;150(6):365-71. Medications the patient is in severe respiratory failure, gasping or apnoeic. describe important historical and clinical ndings that can help be the sole complaint and the physical examination may reveal is is increasingly being used to detect important causes of massive PE should receive intravenous uids and vasopressors 11. Lam LL, Cameron PA, Schneider HG, et al. Meta-analysis: effect of • Crepitations (crackles/rales) suggest the presence of Treatment of a few common conditions is discussed below: B-type natriuretic peptide testing on clinical outcomes in patients with to narrow the dierential diagnosis, discuss the use of common few abnormalities (e.g., pulmonary embolism, A review of the patient's medications, including recent predominantly respiratory in origin, and can prove to be fatal acute dyspnoea like cardiac tamponade, pneumothorax or and commenced on anticoagulant therapy using unfractionated prescriptions (e.g. antibiotics) and their compliance provides interalveolar uid seen in heart failure, pneumonia and with DIFFERENTIAL DIAGNOSIS OF ACUTE sometimes. pleural eusion. It is also being used to detect cardiac wall heparin or a low-molecular-weight heparin, followed by acute dyspnea in the emergency setting. Ann Intern Med. 2010 Dec pneumothorax). 7;153(11):728-35. information about the pre-existing illness. pulmonary brosis. However, the absence of crepitations DYSPNOEA motion abnormalities suggestive of ischaemia or pulmonary Asthma warfarin. Haemodynamically unstable patients should be does not rule out the presence of these pathologies. e cornerstone of management of an asthmatic patient is Chronic dyspnoea develops progressively over weeks to embolism. thrombolysed. If thrombolysis is contraindicated, the patient POTHIAWALA SOHIL Tobacco/Smoking INVESTIGATIONS bronchodilator therapy and steroids (oral prednisone or months. is group of patients are known to have underlying Table 1 describes the common and life-threatening causes of should be referred for embolectomy. Consultant • Diminished breath sounds can be caused by pathology that intravenous hydrocortisone). Bronchodilator therapy using cardiopulmonary disease, the commonest being asthma, Smoking (in pack-years) increases the risk COPD and sudden onset of dyspnoea in an adult, and their main clinical Cardiac biomarkers Department of Emergency Medicine malignancy. prevents air from entering the lungs, such as severe asthma associated signs and symptoms. In children, the causes are Laboratory and radiological tests should be performed in the salbutamol can be delivered through a nebuliser or metred dose Occasionally, it may be dicult to determine the exact cause of Singapore General Hospital COPD, interstitial lung disease, or cardiomyopathy. or COPD, pneumothorax and haemothorax. Elevated cardiac biomarkers support the diagnosis of cardiac

T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 1(3) J UL -S EP 2 0 1 5 : 24 BREATHLESSNESS

In one study of 85 patients presenting to a pulmonary unit Psychiatric conditions appropriate context of the history, physical examination, and ischaemia. Serial measurements of cardiac biomarkers are inhaler (MDI). In severe asthma, patients should be transferred breathlessness. In such cases, it is prudent to start therapies for with a complaint of chronic dyspnoea, the initial impression Psychogenic causes for acute dyspnoea is a diagnosis of the consideration of dierential diagnosis. Random testing necessary as initial results can often be normal. to ED for further treatment with nebulised ipratropium multiple conditions in the initial resuscitative phase. For of the aetiology of dyspnoea based upon the patient history exclusion, and organic causes must be ruled out rst before without a clear dierential diagnosis will delay appropriate bromide, intravenous magnesium, ketamine, IM adrenaline, example, for a patient with a past medical history of COPD and alone was correct in only 66 percent of cases.4 us, a considering this diagnosis (e.g., panic attack).5 management. e use of dyspnoea biomarker panels does not Brain natriuretic peptide (BNP) intubation, and inhalational anaesthesia as needed. congestive cardiac failure, the initial management of sudden systematic approach, comprising of adequate history and appear to improve accuracy beyond clinical assessment and is is used to diagnose heart failure, but it can also be elevated onset of dyspnoea may include therapies directed at both these ABSTRACT diagnostic studies, and provide recommendations for initial physical examination, followed by appropriate investigations focused testing.6, 7 in uid overload secondary to renal failure. BNP testing is not COPD exacerbation conditions. After initial stabilisation, the nal disposition of the Breathlessness, also known as dyspnoea, is a common management and disposition. presenting complaint in the outpatient family physician clinic. is necessary. PHYSICAL EXAMINATION helpful when used indiscriminately in patients with acute Patients with mild exacerbation are treated with nebulised patient depends on your consideration of the dierential It is most commonly caused by respiratory and cardiac Blood tests dyspnea.10, 11 salbutamol, ipratropium and steroids. Antibiotics are indicated diagnosis. Unstable patients should be transported to the disorders, but there are lots of other important aetiologies Signs that suggest severe respiratory distress include e initial evaluation usually includes measurement of if there is evidence of an infective process suggested by fever, emergency department for further evaluation and treatment. that need to be considered. The initial goal of assessment is to EPIDEMIOLOGY HISTORY tachypnoea/bradypnoea, retractions, use of accessory muscles, haemoglobin (to exclude anaemia as a cause of dyspnoea), D-Dimer increased sputum production, or purulent sputum. Patients Patients who are stable should be discharged with appropriate determine the severity of the dyspnoea, considering the need inability to speak in full sentences, inability to lie supine or in for oxygen therapy and intubation. Unstable patients usually A chief complaint of dyspnoea or shortness of breath made up blood glucose (to rule out Kussmaul’s breathing secondary to Patients at low risk for PE according to a validated scoring with moderate to severe respiratory distress should be sent to medications and advised to return back if their condition a tripod position, diaphoresis, agitation or altered mental present with abnormal vital signs, hypoxia, diaphoresis, and/or 3.5 percent of the more than 115 million visits to United States e history forms a critical component in the evaluation of the diabetic ketoacidosis), urea, creatinine and electrolytes. system (Wells criteria for PE, PERC rule) and a negative ED for further management, which can include non-invasive persists or worsens. status, and cyanosis. altered mental states, and require urgent management. EDs in 2003. Other dyspnoea-related chief complaints (cough, dyspnoeic patient, but can be dicult to obtain when the d-dimer can be ruled out for PE without further testing. It ventilation (BiPAP) or endotracheal intubation. Ongoing care depends on the differential diagnosis established chest discomfort) comprised 7.6 percent.2 patient has diculty speaking. Relevant history can be Chest X-ray cannot be used as a rule-out test in patients with moderate to by an adequate history and physical examination, and obtained from the patient, paramedics, family, and caretakers. Retractions occur with airway obstruction (e.g., asthma, e chest radiograph may provide clues to the cause of high pre-test probability of PE. Pneumonia CONCLUSION investigations, if available, can aid definitive diagnosis. The COPD, foreign body) and can be seen in the suprasternal, dysnoea. Patients who are low risk using the CURB-65 score should be family physicians must be equipped to initiate appropriate According to one prospective observational study, the most Present history intercostal, and subcostal areas. ey are an ominous sign e family physicians must be equipped to perform an initial therapy, conduct continuous monitoring and stabilise an common diagnoses among elderly patients presenting to an Arterial and venous blood gas commenced on appropriate antibiotic therapy as per the local suggesting extreme respiratory distress. e use of accessory acutely dyspnoeic patient before determining the final ED with a complaint of acute shortness of breath and Enquire regarding the symptoms, duration, severity, onset - Signs of Acute heart failure are cardiomegaly, cephalisation of e role of the arterial blood gas (ABG) in the diagnosis and antibiotic guidelines and discharged with follow-up within 5-7 assessment, initiate appropriate therapy and stabilise an acutely muscles to breathe suggests fatigue of the respiratory muscles disposition of the patient. manifesting signs of respiratory distress (e.g., respiratory rate whether it is sudden or gradual. Acute dyspnoea following a blood vessels, interstitial oedema ( "Kerley B" lines) and treatment of the acutely dyspnoeic patient is limited. Venous days for re-assessment. Patients with moderate to high risk dyspnoeic patient before determining the disposition of the and a potential for respiratory failure. Diaphoresis reects >25, SpO <93%) are decompensated heart failure, meal or medication suggests an allergic reaction; a new pulmonary vascular congestion. Pleural eusion may be blood gas can be used as an alternate to determine the acid-base should be referred to the hospital for admission and further patient, either discharging home or referring to the emergency Keywords: 2 productive cough suggests chest infection; viral infection or extreme sympathetic stimulation associated with severity of department for further management. pneumonia, chronic obstructive pulmonary disease, present. Around 20 percent of patients admitted with acute status. e PaCO2 levels are low in a breathless patient due to management. In severe pneumonia, 3rd-generation Breathlessness, Dyspnoea, Family Physician, Differential 8 3 allergen exposure can trigger asthma; recent surgery, disease process (myocardial infarction, severe asthma, heart failure may have a non-diagnostic CXR. hyperventilation. A normal or elevated CO in a breathless cephalosporin (ceftriaxone) with a macrolide (azithromycin) is Diagnosis, Management pulmonary embolism, and asthma. 2 immobilisation or long travel time increases the risk for pulmonary oedema). Altered mental status suggests severe patient suggests respiratory failure. the rst-line treatment. In patients with penicillin allergy, a REFERENCES 1. Parshall MB, Schwartzstein RM, Adams L, et al. An official American pulmonary embolism (PE); and trauma may cause hypoxia or hypercarbia, but may also be caused by underlying - In ltrates on CXR are considered the “gold standard” for uoroquinolone should be used. SFP2015; 41(3): 24-29 PATHOPHYSIOLOGY Thoracic Society statement: update on the mechanisms, assessment, pneumothorax or pulmonary contusion. Noncompliance with pathology (e.g., hypoglycaemia, sepsis, poisoning). Cyanosis is diagnosing pneumonia. But X-rays obtained early in the CT orax and management of dyspnea. Am J Respir Crit Care Med. 2012 Feb a late sign and indicates severe hypoxia. 9 e respiratory system is designed to maintain homeostasis medications or increased uid intake may lead to acute clinical course of illness may be non-diagnostic. Also, the A multi-detector computed tomography (MDCT) scan of the Acute Pulmonary Oedema 15;185(4):43552. INTRODUCTION with respect to gas exchange and acid-base status. decompensated heart failure. appearance of the CXR (lobar versus diuse) does not thorax is not indicated in the initial evaluation, but can aid Intravenous frusemide along with sublingual nitroglycerine 2. American College of Emergency Physicians. Vital signs include temperature, heart rate, respiratory rate www.acep.org/webportal/Newsroom/NewsMediaResources/Statistics Derangements in oxygenation, ventilation and acidaemia can accurately predict the aetiology of the pneumonia (typical diagnosis of PE, malignancy, etc. MDCT entails complications tablets/spray should be commenced in the clinic. ey should Dyspnoea, also known as shortness of breath, is one of the Past history and pulse oximetry. Patients with serious underlying disease versus atypical). like contrast-induced nephropathy, contrast allergy, radiation, then be transferred to the nearest ED for further management. Data/default.htm (Accessed on February 04, 2006). lead to dyspnoea. e development of dyspnoea is a complex 3. Ray P, Birolleau S, Lefort Y, et al. Acute respiratory failure in the e patient may have pre-existing illness like asthma, COPD, may have a fast, normal, or slow respiratory rate. e extremes and hence must be used judiciously. most common presentations in the emergency department or a phenomenon generally involving stimulation of a variety of elderly: etiology, emergency diagnosis and prognosis. Crit Care. indicate the severity of the underlying disease process. Pulse primary care setting. e dierential diagnosis ranges from mechanoreceptors throughout the upper airway, lungs, and or ischaemic heart disease, and the dyspnoea can be a result of - A pneumothorax is usually visible on CXR as an area with Pneumothorax 2006;10(3):R82. oximetry is an indicator of arterial oxygenation. It may be simple medical conditions to life-threatening causes, and chest wall, and chemoreceptors at the carotid sinus and the exacerbation of a preexisting illness. e medical records and absence of lung markings. Peak ow and pulmonary function tests (PFTs) For a patient showing signs of tension pneumothorax, needle 4. Pratter MR, Curley FJ, Dubois J, Irwin RS. Cause and evaluation of inaccurate in the setting of hypothermia, shock, carbon establishing a de nitive diagnosis can be challenging. medulla. Respiratory system dyspnoea is related to disorders of medication list can provide important diagnostic clues. e peak expiratory ow rate (PEFR) is useful in determining thoracentesis should be urgently performed in the 2nd chronic dyspnea in a pulmonary disease clinic. Arch Intern Med. 1989 monoxide poisoning, methemoglobinaemia, etc. Oct;149(10):2277-82. the respiratory centre in the brainstem, the respiratory - Hyperinated lung elds and a attened diaphragm are the severity of asthma and response to treatment. intercostal space in the mid-clavicular line on the aected side. Dyspnoea is de ned as the subjective experience of breathing Prior intubation suggestive of air trapping that occurs with COPD or asthma. With the cannula in-situ, the patient can then be transferred by 5. Bass C. Chest pain and breathlessness: relationship to psychiatric muscles, and the lung and alveoli. e cardiovascular system illness. Am J Med. 1992 Jan 24;92(1A):12S-17S. Patients with a history of prior endotracheal intubation have a A thorough systemic examination is an essential part of the Unilateral air trapping suggests obstruction by a foreign body the paramedics to the ED for de nitive management with discomfort that is comprised of qualitatively distinct sensations dyspnoea occurs as a result of cardiac diseases (e.g., acute 6. Singer AJ, Thode HC Jr, Green GB, et al. The incremental benefit of evalution process, and should include inspection, palpation, MANAGEMENT that vary in intensity. e experience derives from interactions myocardial ischaemia, systolic or diastolic heart failure, higher severity risk and the need for subsequent intubation. or mucus plugging. chest-tube insertion. Patients with simple pneumothorax a shortness-of-breath biomarker panel in emergency department percussion and auscultation of the cardio-pulmonary, among multiple physiological, psychological, social, and valvular disorders, pericardial diseases, etc.) and anaemia. A should be commenced on oxygen and referred to the ED for patients with dyspnea. Acad Emerg Med. 2009 Jun;16(6):488-94. Associated Symptoms abdominal and neurological systems. A quick initial assessment will aid the doctor in determining if environmental factors, and may induce secondary combination of these underlying mechanisms can also Electrocardiogram (ECG) further management. 7. Gruson D, Thys F, Ketelslegers JM, et al. Multimarker panel in 1 the patient is stable or unstable. e management is dependent patients admitted to emergency department: a comparison with physiological and behavioral responses. co-exist. Always check for associated symptoms like chest pain (acute coronary syndrome, pneumothorax, PE), fever (infection), During examination of the respiratory system, the following An ECG with ST segment and T-wave changes constitutes on his/her presentation and possible diagnosis, but the initial Pulmonary Embolism reference methods. Clin Biochem. 2009 Feb;42(3):185-8. 8. Collins SP, Lindsell CJ, Storrow AB, et al. Prevalence of negative trauma (pneumothorax, haemothorax), paroxysmal nocturnal abnormal breath sounds should be identi ed: strong evidence of cardiac ischaemia. However, clinicians must treatment includes administration of supplemental oxygen A patient suspected to have PE should be risk strati ed using the A patient with acute dyspnoea presents challenges in diagnosis Evaluation of Dyspnoea chest radiography results in the emergency department patient with using various oxygen delivery devices. You need to be careful and subsequent management. e clinician must consider a Acute dyspnoea is de ned as breathing diculty that arises dyspnoea (heart failure), and haemoptysis (tuberculosis, remember that the initial ECG is normal in approximately 20 Wells criteria for PE or PERC rule for PE. Patients who are low decompensated heart failure. Ann Emerg Med. 2006 Jan;47(1):13-8. • Stridor occurs due to upper airway obstruction. Inspiratory using oxygen in patients with COPD with type 2 respiratory long list of dierential diagnoses while providing appropriate over the course of minutes to hours. Consideration needs to be malignancy, PE). e presence of cough and quality of percent of patients subsequently diagnosed with a myocardial risk and PERC positive should have a D-dimer. If the D-dimer 9. Basi SK, Marrie TJ, Huang JQ, Majumdar SR. Patients admitted to stridor suggests obstruction above the vocal cords (e.g., failure (hypercapnoea) as it may depress their respiratory drive. initial treatment for a potentially life-threatening illness. In this given to relatively few but life-threatening conditions. ese sputum should be enquired as purulent sputum suggests infarction, and only 33 percent of initial ECGs are diagnostic. is negative, PE is ruled out. e chest X-ray is usually normal, hospital with suspected pneumonia and normal chest radiographs: foreign body, epiglottitis, angioedema). Aim to maintain oxygen saturation of around 94 percent. epidemiology, microbiology, and outcomes. Am J Med. 2004 Sep article, we shall review the pathophysiology of dyspnoea, entities typically have associated symptoms and signs that pneumonia, pink frothy sputum suggests heart failure. e ECG may also reveal signs of pulmonary embolism (right but Hampton’s hump or Westermark sign are rare and consideration of the dierential diagnosis, and management. Similarly, dry cough is a non-speci c symptom, and can be heart strain) and pericardial eusion (low-voltage complexes, Establish intravenous access and start administration of uids if diagnostic of PE. Patients who are intermediate or high risk, or 1;117(5):305-11. provide clues to the appropriate diagnosis, e.g., substernal 10. Schneider HG, Lam L, Lokuge A, et al. B-type natriuretic peptide associated with asthma, heart failure, respiratory infection, or • Wheezing occurs as a result of bronchoconstriction and can electrical alternans). indicated. Consider the use of oral or nasopharyngeal airway in who have a positive D-dimer, should have advanced imaging chest pain with cardiac ischaemia; fever, cough, and sputum testing, clinical outcomes, and health services use in emergency be heard in patients with asthma, COPD, anaphylaxis, patients who are unable to maintain their airway due to is topic review will provide a dierential diagnosis of the with respiratory infections; urticaria with anaphylaxis; and PE. like CT pulmonary angiogram. Treatment is largely supportive, department patients with dyspnea: a randomized trial. Ann Intern foreign body obstruction, acute heart failure, or a tumour. depressed levels of consciousness. Intubation may be needed if life-threatening and common causes of dyspnoea in the adult, wheezing with acute bronchospasm. However, dyspnoea may Bedside Ultrasound with oxygen therapy. Patients who are hypotensive due to Med. 2009 Mar 17;150(6):365-71. Medications the patient is in severe respiratory failure, gasping or apnoeic. describe important historical and clinical ndings that can help be the sole complaint and the physical examination may reveal is is increasingly being used to detect important causes of massive PE should receive intravenous uids and vasopressors 11. Lam LL, Cameron PA, Schneider HG, et al. Meta-analysis: effect of • Crepitations (crackles/rales) suggest the presence of Treatment of a few common conditions is discussed below: B-type natriuretic peptide testing on clinical outcomes in patients with to narrow the dierential diagnosis, discuss the use of common few abnormalities (e.g., pulmonary embolism, A review of the patient's medications, including recent predominantly respiratory in origin, and can prove to be fatal acute dyspnoea like cardiac tamponade, pneumothorax or and commenced on anticoagulant therapy using unfractionated prescriptions (e.g. antibiotics) and their compliance provides interalveolar uid seen in heart failure, pneumonia and with DIFFERENTIAL DIAGNOSIS OF ACUTE sometimes. pleural eusion. It is also being used to detect cardiac wall heparin or a low-molecular-weight heparin, followed by acute dyspnea in the emergency setting. Ann Intern Med. 2010 Dec pneumothorax). 7;153(11):728-35. information about the pre-existing illness. pulmonary brosis. However, the absence of crepitations DYSPNOEA motion abnormalities suggestive of ischaemia or pulmonary Asthma warfarin. Haemodynamically unstable patients should be does not rule out the presence of these pathologies. e cornerstone of management of an asthmatic patient is Chronic dyspnoea develops progressively over weeks to embolism. thrombolysed. If thrombolysis is contraindicated, the patient Tobacco/Smoking INVESTIGATIONS bronchodilator therapy and steroids (oral prednisone or months. is group of patients are known to have underlying Table 1 describes the common and life-threatening causes of should be referred for embolectomy. • Diminished breath sounds can be caused by pathology that intravenous hydrocortisone). Bronchodilator therapy using cardiopulmonary disease, the commonest being asthma, Smoking (in pack-years) increases the risk COPD and sudden onset of dyspnoea in an adult, and their main clinical Cardiac biomarkers prevents air from entering the lungs, such as severe asthma Laboratory and radiological tests should be performed in the salbutamol can be delivered through a nebuliser or metred dose COPD, interstitial lung disease, or cardiomyopathy. malignancy. associated signs and symptoms. In children, the causes are Occasionally, it may be dicult to determine the exact cause of or COPD, pneumothorax and haemothorax. Elevated cardiac biomarkers support the diagnosis of cardiac

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In one study of 85 patients presenting to a pulmonary unit Psychiatric conditions Table 1: Common and life-threatening causes of sudden onset of dyspnoea in an adult appropriate context of the history, physical examination, and ischaemia. Serial measurements of cardiac biomarkers are inhaler (MDI). In severe asthma, patients should be transferred breathlessness. In such cases, it is prudent to start therapies for with a complaint of chronic dyspnoea, the initial impression Psychogenic causes for acute dyspnoea is a diagnosis of the consideration of dierential diagnosis. Random testing necessary as initial results can often be normal. to ED for further treatment with nebulised ipratropium multiple conditions in the initial resuscitative phase. For of the aetiology of dyspnoea based upon the patient history exclusion, and organic causes must be ruled out rst before Differential Diagnosis Key Clinical Features without a clear dierential diagnosis will delay appropriate bromide, intravenous magnesium, ketamine, IM adrenaline, example, for a patient with a past medical history of COPD and 4 considering this diagnosis (e.g., panic attack).5 management. e use of dyspnoea biomarker panels does not Brain natriuretic peptide (BNP) intubation, and inhalational anaesthesia as needed. congestive cardiac failure, the initial management of sudden alone was correct in only 66 percent of cases. us, a ABSTRACT systematic approach, comprising of adequate history and appear to improve accuracy beyond clinical assessment and is is used to diagnose heart failure, but it can also be elevated onset of dyspnoea may include therapies directed at both these diagnostic studies, and provide recommendations for initial Upper airway obstruction: 6, 7 Breathlessness, also known as dyspnoea, is a common physical examination, followed by appropriate investigations - Choking, stridor focused testing. in uid overload secondary to renal failure. BNP testing is not COPD exacerbation conditions. After initial stabilisation, the nal disposition of the management and disposition. PHYSICAL EXAMINATION - Foreign body presenting complaint in the outpatient family physician clinic. is necessary. - Rash, allergy exposure, oral swelling, wheeze helpful when used indiscriminately in patients with acute Patients with mild exacerbation are treated with nebulised patient depends on your consideration of the dierential It is most commonly caused by respiratory and cardiac - Angioedema 10, 11 - Drooling, stridor, fever, toxic look Blood tests dyspnea. salbutamol, ipratropium and steroids. Antibiotics are indicated diagnosis. Unstable patients should be transported to the disorders, but there are lots of other important aetiologies Signs that suggest severe respiratory distress include - epiglottitis e initial evaluation usually includes measurement of if there is evidence of an infective process suggested by fever, emergency department for further evaluation and treatment. that need to be considered. The initial goal of assessment is to EPIDEMIOLOGY - Fever, barking cough, stridor HISTORY tachypnoea/bradypnoea, retractions, use of accessory muscles, haemoglobin (to exclude anaemia as a cause of dyspnoea), D-Dimer increased sputum production, or purulent sputum. Patients Patients who are stable should be discharged with appropriate determine the severity of the dyspnoea, considering the need - croup inability to speak in full sentences, inability to lie supine or in for oxygen therapy and intubation. Unstable patients usually A chief complaint of dyspnoea or shortness of breath made up blood glucose (to rule out Kussmaul’s breathing secondary to Patients at low risk for PE according to a validated scoring with moderate to severe respiratory distress should be sent to medications and advised to return back if their condition a tripod position, diaphoresis, agitation or altered mental present with abnormal vital signs, hypoxia, diaphoresis, and/or 3.5 percent of the more than 115 million visits to United States e history forms a critical component in the evaluation of the Cardiac: diabetic ketoacidosis), urea, creatinine and electrolytes. system (Wells criteria for PE, PERC rule) and a negative ED for further management, which can include non-invasive persists or worsens. status, and cyanosis. - Tachycardia, fluid retention, cough altered mental states, and require urgent management. EDs in 2003. Other dyspnoea-related chief complaints (cough, dyspnoeic patient, but can be dicult to obtain when the - congestive heart failure d-dimer can be ruled out for PE without further testing. It ventilation (BiPAP) or endotracheal intubation. Ongoing care depends on the differential diagnosis established 2 patient has diculty speaking. Relevant history can be - Pink frothy sputum, diaphoresis, chest discomfort) comprised 7.6 percent. - acute pulmonary oedema Chest X-ray cannot be used as a rule-out test in patients with moderate to by an adequate history and physical examination, and obtained from the patient, paramedics, family, and caretakers. Retractions occur with airway obstruction (e.g., asthma, hypertension e chest radiograph may provide clues to the cause of high pre-test probability of PE. Pneumonia CONCLUSION investigations, if available, can aid definitive diagnosis. The COPD, foreign body) and can be seen in the suprasternal, dysnoea. Patients who are low risk using the CURB-65 score should be family physicians must be equipped to initiate appropriate According to one prospective observational study, the most - Chest pain, diaphoresis Present history intercostal, and subcostal areas. ey are an ominous sign - acute myocardial infarction e family physicians must be equipped to perform an initial therapy, conduct continuous monitoring and stabilise an common diagnoses among elderly patients presenting to an - Tachycardia, +/- hypotension Arterial and venous blood gas commenced on appropriate antibiotic therapy as per the local suggesting extreme respiratory distress. e use of accessory - arrhythmia acutely dyspnoeic patient before determining the final ED with a complaint of acute shortness of breath and Enquire regarding the symptoms, duration, severity, onset - Hypotension, muffled heart sounds, raised - Signs of Acute heart failure are cardiomegaly, cephalisation of e role of the arterial blood gas (ABG) in the diagnosis and antibiotic guidelines and discharged with follow-up within 5-7 assessment, initiate appropriate therapy and stabilise an acutely muscles to breathe suggests fatigue of the respiratory muscles - Cardiac tamponade disposition of the patient. manifesting signs of respiratory distress (e.g., respiratory rate whether it is sudden or gradual. Acute dyspnoea following a JVP blood vessels, interstitial oedema ( "Kerley B" lines) and treatment of the acutely dyspnoeic patient is limited. Venous days for re-assessment. Patients with moderate to high risk dyspnoeic patient before determining the disposition of the and a potential for respiratory failure. Diaphoresis reects >25, SpO <93%) are decompensated heart failure, meal or medication suggests an allergic reaction; a new pulmonary vascular congestion. Pleural eusion may be blood gas can be used as an alternate to determine the acid-base should be referred to the hospital for admission and further patient, either discharging home or referring to the emergency Keywords: 2 productive cough suggests chest infection; viral infection or extreme sympathetic stimulation associated with severity of Pulmonary: department for further management. pneumonia, chronic obstructive pulmonary disease, present. Around 20 percent of patients admitted with acute status. e PaCO2 levels are low in a breathless patient due to management. In severe pneumonia, 3rd-generation Breathlessness, Dyspnoea, Family Physician, Differential - Cough, sputum change, +/- fever, wheeze 8 3 allergen exposure can trigger asthma; recent surgery, disease process (myocardial infarction, severe asthma, heart failure may have a non-diagnostic CXR. hyperventilation. A normal or elevated CO in a breathless cephalosporin (ceftriaxone) with a macrolide (azithromycin) is Diagnosis, Management pulmonary embolism, and asthma. - chronic obstructive pulmonary 2 immobilisation or long travel time increases the risk for pulmonary oedema). Altered mental status suggests severe patient suggests respiratory failure. the rst-line treatment. In patients with penicillin allergy, a REFERENCES disease 1. Parshall MB, Schwartzstein RM, Adams L, et al. An official American pulmonary embolism (PE); and trauma may cause hypoxia or hypercarbia, but may also be caused by underlying - In ltrates on CXR are considered the “gold standard” for uoroquinolone should be used. SFP2015; 41(3): 24-29 PATHOPHYSIOLOGY - asthma - Tachypnoea, wheeze, tripod, diaphoresis Thoracic Society statement: update on the mechanisms, assessment, pneumothorax or pulmonary contusion. Noncompliance with pathology (e.g., hypoglycaemia, sepsis, poisoning). Cyanosis is - pneumonia - Fever, cough, chest pain diagnosing pneumonia. But X-rays obtained early in the CT orax and management of dyspnea. Am J Respir Crit Care Med. 2012 Feb medications or increased uid intake may lead to acute a late sign and indicates severe hypoxia. clinical course of illness may be non-diagnostic.9 Also, the A multi-detector computed tomography (MDCT) scan of the Acute Pulmonary Oedema e respiratory system is designed to maintain homeostasis - pneumothorax 15;185(4):43552. INTRODUCTION with respect to gas exchange and acid-base status. decompensated heart failure. appearance of the CXR (lobar versus diuse) does not thorax is not indicated in the initial evaluation, but can aid Intravenous frusemide along with sublingual nitroglycerine 2. American College of Emergency Physicians. Vital signs include temperature, heart rate, respiratory rate • tension - Chest pain, tracheal deviation, hypotension www.acep.org/webportal/Newsroom/NewsMediaResources/Statistics Derangements in oxygenation, ventilation and acidaemia can accurately predict the aetiology of the pneumonia (typical diagnosis of PE, malignancy, etc. MDCT entails complications tablets/spray should be commenced in the clinic. ey should Dyspnoea, also known as shortness of breath, is one of the Past history and pulse oximetry. Patients with serious underlying disease • simple - Chest pain, past history versus atypical). like contrast-induced nephropathy, contrast allergy, radiation, then be transferred to the nearest ED for further management. Data/default.htm (Accessed on February 04, 2006). lead to dyspnoea. e development of dyspnoea is a complex 3. Ray P, Birolleau S, Lefort Y, et al. Acute respiratory failure in the e patient may have pre-existing illness like asthma, COPD, may have a fast, normal, or slow respiratory rate. e extremes and hence must be used judiciously. most common presentations in the emergency department or a phenomenon generally involving stimulation of a variety of elderly: etiology, emergency diagnosis and prognosis. Crit Care. indicate the severity of the underlying disease process. Pulse primary care setting. e dierential diagnosis ranges from mechanoreceptors throughout the upper airway, lungs, and or ischaemic heart disease, and the dyspnoea can be a result of - pulmonary embolism - Pleuritic chest pain, tachycardia, DVT risk - A pneumothorax is usually visible on CXR as an area with Pneumothorax 2006;10(3):R82. oximetry is an indicator of arterial oxygenation. It may be simple medical conditions to life-threatening causes, and chest wall, and chemoreceptors at the carotid sinus and the exacerbation of a preexisting illness. e medical records and absence of lung markings. Peak ow and pulmonary function tests (PFTs) For a patient showing signs of tension pneumothorax, needle 4. Pratter MR, Curley FJ, Dubois J, Irwin RS. Cause and evaluation of inaccurate in the setting of hypothermia, shock, carbon establishing a de nitive diagnosis can be challenging. medulla. Respiratory system dyspnoea is related to disorders of medication list can provide important diagnostic clues. e peak expiratory ow rate (PEFR) is useful in determining thoracentesis should be urgently performed in the 2nd chronic dyspnea in a pulmonary disease clinic. Arch Intern Med. 1989 monoxide poisoning, methemoglobinaemia, etc. Oct;149(10):2277-82. the respiratory centre in the brainstem, the respiratory Trauma: - Hyperinated lung elds and a attened diaphragm are the severity of asthma and response to treatment. intercostal space in the mid-clavicular line on the aected side. Dyspnoea is de ned as the subjective experience of breathing Prior intubation suggestive of air trapping that occurs with COPD or asthma. With the cannula in-situ, the patient can then be transferred by 5. Bass C. Chest pain and breathlessness: relationship to psychiatric muscles, and the lung and alveoli. e cardiovascular system - Pneumothorax/hemothorax/flail chest - History of trauma, decreased breath sounds illness. Am J Med. 1992 Jan 24;92(1A):12S-17S. discomfort that is comprised of qualitatively distinct sensations Patients with a history of prior endotracheal intubation have a A thorough systemic examination is an essential part of the Unilateral air trapping suggests obstruction by a foreign body the paramedics to the ED for de nitive management with dyspnoea occurs as a result of cardiac diseases (e.g., acute 6. Singer AJ, Thode HC Jr, Green GB, et al. The incremental benefit of evalution process, and should include inspection, palpation, MANAGEMENT that vary in intensity. e experience derives from interactions myocardial ischaemia, systolic or diastolic heart failure, higher severity risk and the need for subsequent intubation. or mucus plugging. chest-tube insertion. Patients with simple pneumothorax a shortness-of-breath biomarker panel in emergency department percussion and auscultation of the cardio-pulmonary, Psychogenic: among multiple physiological, psychological, social, and valvular disorders, pericardial diseases, etc.) and anaemia. A should be commenced on oxygen and referred to the ED for patients with dyspnea. Acad Emerg Med. 2009 Jun;16(6):488-94. Associated Symptoms abdominal and neurological systems. - panic attacks/hyperventilation - Anxiety, past history, perioral and distal A quick initial assessment will aid the doctor in determining if environmental factors, and may induce secondary combination of these underlying mechanisms can also Electrocardiogram (ECG) further management. 7. Gruson D, Thys F, Ketelslegers JM, et al. Multimarker panel in 1 paraesthesia, tetany the patient is stable or unstable. e management is dependent patients admitted to emergency department: a comparison with physiological and behavioral responses. co-exist. Always check for associated symptoms like chest pain (acute coronary syndrome, pneumothorax, PE), fever (infection), During examination of the respiratory system, the following An ECG with ST segment and T-wave changes constitutes on his/her presentation and possible diagnosis, but the initial Pulmonary Embolism reference methods. Clin Biochem. 2009 Feb;42(3):185-8. 8. Collins SP, Lindsell CJ, Storrow AB, et al. Prevalence of negative trauma (pneumothorax, haemothorax), paroxysmal nocturnal abnormal breath sounds should be identi ed: Others strong evidence of cardiac ischaemia. However, clinicians must treatment includes administration of supplemental oxygen A patient suspected to have PE should be risk strati ed using the A patient with acute dyspnoea presents challenges in diagnosis Evaluation of Dyspnoea chest radiography results in the emergency department patient with using various oxygen delivery devices. You need to be careful and subsequent management. e clinician must consider a Acute dyspnoea is de ned as breathing diculty that arises dyspnoea (heart failure), and haemoptysis (tuberculosis, - metabolic acidosis - Precipitating cause – hyperglycaemia, sepsis remember that the initial ECG is normal in approximately 20 Wells criteria for PE or PERC rule for PE. Patients who are low decompensated heart failure. Ann Emerg Med. 2006 Jan;47(1):13-8. • Stridor occurs due to upper airway obstruction. Inspiratory using oxygen in patients with COPD with type 2 respiratory long list of dierential diagnoses while providing appropriate over the course of minutes to hours. Consideration needs to be malignancy, PE). e presence of cough and quality of - Poisoning - Carbon monoxide, cyanide, aspirin, etc. percent of patients subsequently diagnosed with a myocardial risk and PERC positive should have a D-dimer. If the D-dimer 9. Basi SK, Marrie TJ, Huang JQ, Majumdar SR. Patients admitted to stridor suggests obstruction above the vocal cords (e.g., failure (hypercapnoea) as it may depress their respiratory drive. initial treatment for a potentially life-threatening illness. In this given to relatively few but life-threatening conditions. ese sputum should be enquired as purulent sputum suggests - neuromuscular disorders - Guillain-Barre syndrome, Amyotrophic infarction, and only 33 percent of initial ECGs are diagnostic. is negative, PE is ruled out. e chest X-ray is usually normal, hospital with suspected pneumonia and normal chest radiographs: foreign body, epiglottitis, angioedema). Aim to maintain oxygen saturation of around 94 percent. epidemiology, microbiology, and outcomes. Am J Med. 2004 Sep article, we shall review the pathophysiology of dyspnoea, entities typically have associated symptoms and signs that pneumonia, pink frothy sputum suggests heart failure. lateral sclerosis e ECG may also reveal signs of pulmonary embolism (right but Hampton’s hump or Westermark sign are rare and consideration of the dierential diagnosis, and management. Similarly, dry cough is a non-speci c symptom, and can be heart strain) and pericardial eusion (low-voltage complexes, Establish intravenous access and start administration of uids if diagnostic of PE. Patients who are intermediate or high risk, or 1;117(5):305-11. provide clues to the appropriate diagnosis, e.g., substernal - pain - Precipitating cause of pain 10. Schneider HG, Lam L, Lokuge A, et al. B-type natriuretic peptide associated with asthma, heart failure, respiratory infection, or • Wheezing occurs as a result of bronchoconstriction and can electrical alternans). indicated. Consider the use of oral or nasopharyngeal airway in who have a positive D-dimer, should have advanced imaging chest pain with cardiac ischaemia; fever, cough, and sputum testing, clinical outcomes, and health services use in emergency be heard in patients with asthma, COPD, anaphylaxis, - anaemia - Pallor, fatigue, blood loss patients who are unable to maintain their airway due to is topic review will provide a dierential diagnosis of the with respiratory infections; urticaria with anaphylaxis; and PE. like CT pulmonary angiogram. Treatment is largely supportive, department patients with dyspnea: a randomized trial. Ann Intern foreign body obstruction, acute heart failure, or a tumour. depressed levels of consciousness. Intubation may be needed if life-threatening and common causes of dyspnoea in the adult, wheezing with acute bronchospasm. However, dyspnoea may Bedside Ultrasound with oxygen therapy. Patients who are hypotensive due to Med. 2009 Mar 17;150(6):365-71. Medications the patient is in severe respiratory failure, gasping or apnoeic. describe important historical and clinical ndings that can help be the sole complaint and the physical examination may reveal is is increasingly being used to detect important causes of massive PE should receive intravenous uids and vasopressors 11. Lam LL, Cameron PA, Schneider HG, et al. Meta-analysis: effect of • Crepitations (crackles/rales) suggest the presence of Treatment of a few common conditions is discussed below: B-type natriuretic peptide testing on clinical outcomes in patients with to narrow the dierential diagnosis, discuss the use of common few abnormalities (e.g., pulmonary embolism, A review of the patient's medications, including recent predominantly respiratory in origin, and can prove to be fatal acute dyspnoea like cardiac tamponade, pneumothorax or and commenced on anticoagulant therapy using unfractionated prescriptions (e.g. antibiotics) and their compliance provides interalveolar uid seen in heart failure, pneumonia and with DIFFERENTIAL DIAGNOSIS OF ACUTE sometimes. pleural eusion. It is also being used to detect cardiac wall heparin or a low-molecular-weight heparin, followed by acute dyspnea in the emergency setting. Ann Intern Med. 2010 Dec pneumothorax). 7;153(11):728-35. information about the pre-existing illness. pulmonary brosis. However, the absence of crepitations DYSPNOEA motion abnormalities suggestive of ischaemia or pulmonary Asthma warfarin. Haemodynamically unstable patients should be does not rule out the presence of these pathologies. e cornerstone of management of an asthmatic patient is Chronic dyspnoea develops progressively over weeks to embolism. thrombolysed. If thrombolysis is contraindicated, the patient Tobacco/Smoking INVESTIGATIONS bronchodilator therapy and steroids (oral prednisone or months. is group of patients are known to have underlying Table 1 describes the common and life-threatening causes of should be referred for embolectomy. • Diminished breath sounds can be caused by pathology that intravenous hydrocortisone). Bronchodilator therapy using cardiopulmonary disease, the commonest being asthma, Smoking (in pack-years) increases the risk COPD and sudden onset of dyspnoea in an adult, and their main clinical Cardiac biomarkers prevents air from entering the lungs, such as severe asthma Laboratory and radiological tests should be performed in the salbutamol can be delivered through a nebuliser or metred dose COPD, interstitial lung disease, or cardiomyopathy. malignancy. associated signs and symptoms. In children, the causes are Occasionally, it may be dicult to determine the exact cause of or COPD, pneumothorax and haemothorax. Elevated cardiac biomarkers support the diagnosis of cardiac

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T H E S I N G A P O R E F A M I L Y P H Y S I C I A N V O L 4 1(3) J UL -S EP 2 0 1 5 : 27 BREATHLESSNESS

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LEARNING POINTS

• Acute dyspnoea is most commonly caused by respiratory and cardiac aetiologies, but there are lots of other aetiologies that also need to be considered. • The initial goal of assessment is to determine the severity of the dyspnoea and identify unstable patients with a risk of deterioration. • The family physicians must initiate appropriate therapy based on the differential diagnosis, stabilise an acutely dyspnoeic patient and decide on appropriate disposition.

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