Junior Doctor Notes 🩺

Shortness of Breath, Cough and Haemopytsis

7 min read

Phone Call/Presentation Questions

  • Reason for admission
  • Is the patient symptomatic:
    • Is the patient cyanosed ⇒ immediate review if so
    • How long has the patient had SOB (i.e. is it sudden ⇒ Pulmonary Embolism or Pneumothorax → immediate review)
    • Associated symptoms: chest pain, cough, fever, stridor, wheeze and facial oedema?
  • Other observations
    • Vital signs
  • Does the patient have a history of Heart Failure or Acute Pulmonary Oedema or of Asthma Exacerbation or COPD?
  • Does the patient have massive haemoptysis ⇒immediate review

Instructions over the phone

  • Ask for measurement of the oxygen saturation by non-invasive pulse oximetry
  • Give oxygen by mask to maintain saturation >95%
  • Request as high a concentration of in the short term unless the patient has significant COPD → 28% by Venturi mask and reassess at the bedside
  • Ask the nurse to bring the resuscitation trolley to the bedside, attach an ECG monitor to the patient and gain IV access
  • Request nebulised salbutamol 5mg (1mL) diluted with 3mL of normal saline if the patient has asthma or wheeze
  • Request GTN SL (0.4mg by spray or 0.6mg tablet) if the patient is hypertensive, has chest pain or a history of Heart Failure; repeat in 5-10 minutes only if SBP remains >100mmHg

Common Causes (Corridor thoughts)

Dyspnoea

Cough

  • Any cardiopulmonary causes as above
  • Upper airway stimuli
    • Viral illness or postviral syndromes
    • Sinusitis
    • Gastro-oesophageal reflux
    • Inhalational injury
    • Allergy
    • Malignancy
    • ACE inhibitors (inc. angio-oedema)

Haemoptysis

Massive haemoptysis

Haemoptysis of 100-200mL can cause complete airway flooding and asphyxiation Management

  • Apply high dose oxygen and order immediate CXR
  • Large bore peripheral IV access and take bloods including coagulation studies and cross match
  • Call ICU and anaesthetics for inutbation with double-lumen tube
  • If or once stable chest CT and bronchoscopy or consider interventional radiology embolisation

Assessment

End of Bed

  • Does the patient look short of breath?
  • Are they able to speak full sentences?
  • Seated upright?

A → E Assessment

  • A
    • Is the airway patent?
      • Suspect upper airway obstruction if the patient is making breathing efforts (e.g. tachypnoea, agitation, increased WOB) but has stridor and impaired air entry
      • Upper airway obstruction causes:
        • Pharyngeal soft-tissue obstruction from loss of airway tone, infection (e.g. croup, epiglottitis), Angio-oedema from anaphylaxis or medications (ACE-i)
        • Food bolus or other foreign material in the posterior pharynx or trachea
        • Burns
        • Tumour
        • Laryngospasm
  • B
    • Respiratory rate and pattern?
      • See Acute Respiratory Failure
      • RR <10 breaths/min ⇒ central depression of ventilation usually due to intracerebral event, drug toxicity (e.g. opioids) or profound hypercarbia
      • RR >20 breaths/min ⇒ increased work of breathing secondary to hypoxia, acidosis, reflex stimulation or pain
      • Be aware of see-saw movements of the chest cage and abdominal wall; manage as Acute Respiratory Failure
      • Look for unequal chest expansion associated with hyperresonance and hyperinflation with tracheal deviation to the opposite side (Tension Pneumothorax)
  • C
    • Heart rate?
      • Sinus tachycardia is common but bradycardia from hypoxia is pre-terminal
    • Blood pressure?
    • JVP?
  • D
  • E
    • Temperature?
      • Elevated temperature suggests infection
      • Low grade fever also happens in Pulmonary Embolism (esp. in <35 years old)
ExaminationNotes
VitalsRepeat them
HEENTCheck for central cyanosis
RespCheck for wheeze, crackles, consolidation (bronchial breathing, pneumothorax, or pleural effusion)

Immediate management of the hypoxic patient

  • If the patient is not breathing or is making inadequate breathing efforts → head tilt-chin lift or jaw thrust to open the airway and begin ventilation with a bag-mask device connected to high-dose oxygen
    • Call senior, ICU or anaesthetics immediate (or MET Activation Criteria)
    • Ensure airway is clear of foreign material using suction
    • Insert oropharyngeal airway if tolerated by the patient
  • Do not interfere if patient is coughing and clearing their airway; see Choking
  • If the patient is making adequate respiratory efforts
    • Deliver enough oxygen:
      • Give 4-15L/min oxygen by mask to keep oxygen saturation >95%
      • Titrating oxygen once stabilised
      • Attach pulse oximetry
  • Obtain IV access and take bloods for FBC & UEC and request portable chest X-ray and perform an ECG
  • Obtain a VBG or ABG
  • Provide urgent interventions for life-threatening causes
    • Tension pneumothorax → needle decompression of the chest if the patient is in extreme respiratory distress or hypotense; wide-bore cannula into the second intercostal space in the mid clavicular line
    • Give nebulised salbutamol 5mg diluted in 3mL of normal saline for wheeze
    • Give GTN 0.6mg SL and repeat twice further, provided SBP is >100 mmHg if chest has crackles and Acute Pulmonary Oedema is suspected

Selective History and Chart Review

  • Reason for patient admission?
  • Was SOB sudden or gradual onset?
  • Chest pain and character?
  • Cough? Sputum?
    • Coloured sputum (green, yellow, brown or blood-streaked) suggests an infective source
    • Blood-stained frothy sputum is usually associated with acute LVF
    • Mucoid sputum, produced on a regular basis, is most commonly associated with chronic bronchitis
    • Dry, persistent cough may be caused by an ACE inhibitor, asthma, sinusitis, postviral syndrome or gastro-oesophageal reflux
  • Haemoptysis? Estimated volume?
    • History of malignancy, TB, pulmonary vasculitis or Pulmonary Hypertension
    • Haemoptysis in PE is rare as most do not cause pulmonary infarction
  • Audible wheeze?
    • Sign of reversible airway obstruction in patients with known history of Asthma Exacerbation or COPD
    • Bronchospasm can also happen in other conditions
  • Fever? Chills?
    • Check temperature chart since admission
    • Pulmonary Embolism and postoperative atelactasis are also associated with low-grade fever
  • Recent surgery?
    • All postoperative → ↑ risk of atelactasis w/ or w/o consolidation and/or Pulmonary Embolism
    • Thoracic surgery → ↑ risk of Pneumothorax, haemothoracic and cardiac tamponade
    • Pain after surgery ↑ risk of atelactasis
    • Abdominal distension → ↓ ventilation and ↑ dyspnoea
  • Mobilisation (especially if post-op)
  • Prior status (e.g. previously independent)
  • Central line placed recently?
    • ? Iatrogenic pneumothorax
    • ? Cardiac tamponade
  • PMHx?
  • Review charts
    • Check previous vital signs
    • Review fluid balance → persistent positive fluid balance may be assocaited with fluid overload
    • ? DVT prophylaxis
  • Medication chart

Examination

  • Chest sounds
  • Heart sounds
  • Lower leg swelling (? DVT)
ExaminationNotes
VitalsRepeat
CVSDistended neck veins ⇒ massive PE, cardiogenic failure, tension pneumothorax, cardiac tamponade
Peripherally shut down with clammy skin ⇒ Shock (cardiogenic, obstructive or hypovolaemic)
Arrhythmia (LVE, PE)
S3 gallop ⇒ LV Heart Failure
Loud P2 ⇒ COPD, Pulmonary Hypertension)
Systolic murmur ⇒ LV Heart Failure
Wheeze (Asthma Exacerbation, COPD, foreign body aspiration)
RespStridor, hoarse voice, inability to speak (upper airway obstruction, Anaphylaxis)
Limited inspiration and splinted chest wall 2° to pleuritic chest pain ⇒ Pneumothorax, Pulmonary Embolism, Pneumonia
Basal crackles ⇒ LV Heart Failure
Hyperexpanded, hyperresonant ⇒ Pneumothorax
Subcutaneous emphysema ⇒ Pneumothorax
Pulmonary consolidation ⇒ Pneumonia, Pulmonary Embolism with infarction
Pleural effusion ⇒ LV Heart Failure, malignancy, PE, Pneumonia
GITDistension and ascites with tender hepatomegaly ⇒ RV Heart Failure or CCF
OtherPeripheral oedema w/ accentuated skin creases on posterior thorax and taut, noncompliant skin ⇒ RV Heart Failure or CCF
Tender swollen thigh (DVT with PE)

Investigations

  • Bedside:
    • ECG
      • Review ECG evidence of cardiac disease or indirect evidence of PE
      • Pulmonary embolism
        • Significant PE may cause right axis deviation and right BBB but most common sign is sinus tachycardia (S1Q3T3 is neither specific nor sensitive for PE)
        • Other ECG findings: Qr in V1, STE in V1, Complete RBBB, S1Q3T3, R axis deviation, STE in III, STD in V4-6, AF, TWI in precordial/inferior leads
        Link to original
    • Peak exiratory flow rate to quantify bronchospasm and improvement after bronchodilator therapy
    • VBG or ABG
    • Lung POCUS
  • Bloods:
    • FBC, UEC, cardiac enzymes and LFTs
      • Cardiac markers only if suspicious of ACS or worsened CCF
  • Imaging:
    • CXR
      • Pneumonia
        • Infiltrates (can be unilateral or bilateral or lobar or patchy)
        • Parapneumonic effusion
        Link to original
      • COPD/Asthma; CXR not required in exacerbations of asthma that respond promptly to treatment
        • Hyperinflation of the lungs with flattened diaphragms
        • Increased anteroposterior diameter
        • Occasional infiltrates
        • Occasionally pneumomediastinum
        Link to original
      • APO
        • Alveolar oedema (‘batwing’ appearance)
        • Kerly B lines (1-2cm horizontal, peripheral engorged subpleural lymphatics) and septal lines
        • Cardiomegaly
        • Upper love diversion
        • Pleural effusion
        • Additionally to ABCDE features above; it may show a precipitating cause such as a pneumonia
        Link to original
      • Pulmonary embolism
        • Frequently normal; mainly to exclude other diagnoses such as pneumonia or pneumothorax
        • Plate or linear atelactasis
        • Unilateral pleural based wedge shaped pulmonary infiltrate
        • Unilateral pleural effusion
        • Raised hemidiaphragm
        • Dilated pulmonary artery in massive PE
        • Areas of oligaemia in massive PE
        Link to original

Specific Management

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