- Also see Acute Respiratory Failure
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
- Pulmonary causes
- Pneumonia
- Bronchospasm with wheeze (Asthma Exacerbation, COPD, Anaphylaxis)
- Pneumothorax
- Massive pleural effusion
- Aspiration of gastric contents or other foreign material
- Atelactasis (especially post-operative)
- Interstitial lung disease (sarcoid, occupational, hypersensitivity, drugs)
- Pulmonary Hypertension
- Cardiovascular causes
- Miscellaneous
- Upper airway obstruction (with stridor; see Acute Airway Failure)
- Metabolic acidosis (DKA, Sepsis)
- Neuromuscular weakness (Guillain-Barré syndrome, myaesthenia gravis, muscular dystrophy)
- Anaemia
- Hyperthyroidism
- Poisoning (aspirin, carbon monoxide)
- Anxiety
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
- Chest infection including Pneumonia, COPD and TB
- Lung cancer
- Benign tumours or AV malformations
- Pulmonary Embolism
- Bronchiectasis
- Acute Pulmonary Oedema (blood stained frothy sputum)
- Pulmonary vasculitis (Goodpasture, Wegener)
- Pulmonary Hypertension
- Upper airway origin
- Foreign body
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
- Is the airway patent?
- 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)
- Respiratory rate and pattern?
- C
- Heart rate?
- Sinus tachycardia is common but bradycardia from hypoxia is pre-terminal
- Blood pressure?
- Hypotension may indicate Pneumothorax, cardiac tamponade, massive Pulmonary Embolism, septic shock, cardiogenic shock or occult haemorrhage
- Hypertension may be associated with Acute Pulmonary Oedema
- JVP?
- Raised JVP suggests massive Pulmonary Embolism, cardiogenic shock, tension Pneumothorax or cardiac tamponade
- Heart rate?
- D
- E
- Temperature?
- Elevated temperature suggests infection
- Low grade fever also happens in Pulmonary Embolism (esp. in <35 years old)
- Temperature?
| Examination | Notes |
|---|---|
| Vitals | Repeat them |
| HEENT | Check for central cyanosis |
| Resp | Check 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
- Deliver enough oxygen:
- 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?
- Sudden ⇒ Pneumothorax, Pulmonary Embolism and inhaled foreign body
- Gradual ⇒ Pneumonia
- Orthopnoea or paroxysmal nocturnal dyspnoea ⇒ LV Heart Failure
- Chest pain and character?
- Central, heavy chest pain radiating to the neck, jaw or arms ⇒ Acute Coronary Syndromes or LV Heart Failure
- Pleuritic chest pain ⇒ Pneumonia, Pulmonary Embolism or Pneumothorax
- Pulmonary Embolism is characterised by a sudden onset SOB with non-radiating chest pain which can be a central constant ache or lateral pleuritic pain
- 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)
| Examination | Notes |
|---|---|
| Vitals | Repeat |
| CVS | Distended 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) | |
| Resp | Stridor, 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 | |
| GIT | Distension and ascites with tender hepatomegaly ⇒ RV Heart Failure or CCF |
| Other | Peripheral 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
- Peak exiratory flow rate to quantify bronchospasm and improvement after bronchodilator therapy
- VBG or ABG
- Lung POCUS
- ECG
- Bloods:
- FBC, UEC, cardiac enzymes and LFTs
- Cardiac markers only if suspicious of ACS or worsened CCF
- FBC, UEC, cardiac enzymes and LFTs
- Imaging:
- CXR
- Pneumonia
- Infiltrates (can be unilateral or bilateral or lobar or patchy)
- Parapneumonic effusion
- 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
- 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
- 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
- Pneumonia
- CXR