1. Breathlessness : emergency
presentations
 Wheezing?
 Asthma
 COPD
 HeartFailure
 Anaphylaxis

2.  Stridor? (Upper airway obstruction)
 Foreignbody or tumour
 Acute epiglottitis
 Anaphylaxis
 Trauma, eg laryngeal fracture
 Crepitations?
 Heart failure
 Pneumonia
 Bronchiectasis
 Fibrosis

3.  Chest clear?
 Pulmonary embolism
 Hyperventilation
 Metabolic acidosis, eg diabetic ketoacidosis
(DKA)
 Anaemia
 Drugs, eg: salicylates
 Shock (may cause air hunger)
 Pneumocystis pneumonia
 Central causes
 Others
 Pneumothorax – pain, increased resonance
 Pleural effusion – 'stony dullness'

4. Priority management of acute
breathlessness

5. Acute breathlessness
Oxygen, ECG monitor, Check BP, Listen over lungs, IV cannula, Nebulized
salbutamol if wheeze
Sign of tension Decompress with large-bore needle, 2nd
pneumothorax intercostal space in mid-clavicular line
Major arrhythmia? Treat
No
Clinical assessment, Chest X-ray,
Arterial blood gases, 12 lead ECG
Chest X-ray clear
Chest X-ray
abnormal Consider: - Acute asthma
- Exacerbation of COPD
- Upper airways obstruction
- Pulmonary embolism
Specific diagnosis and
-Pre-radiological pneumonia
treatment
- Sepsis syndrome

6. Urgent investigations in acute
breathlessness
 Chest X-ray
 Arterial blood gases and pH if oxygen saturation
is <90% or diagnosis is unclear
 ECG(except in patients under 40 with
pneumothorax or acute asthma)
 Full blood count
 Creatinine, sodium, potassium and glucose
 Echocardiogram if:
 Suspected cardiac tamponade
 Suspected surgically correctable cause of pulmonary
oedema

7. Features pointing to a diagnosis in
the breathless patient

8. Diagnosis Features
Acute asthma Wheeze with reduced peak flow rate
Previous similar episodes responding to bronchodilator therapy
Diurnal and seasonal variation in symptoms
Symptoms provoked by allergen exposure or exercise
Sleep disturbance by breathlessness and wheeze
Pulmonary oedema Cardiac disease
Abnormal ECG
Bilateral interstitial or alveolar shadowing on chest x-ray

9. Pneumonia Fever
Productive cough
Pleuritic chest pain
Focal shadowing on
chest X-ray
Exacerbation of chronic
obstructive pulmonary Increase in sputum volume, tenacity
disease or purulence
Previous chronic bronchitis: sputum production
daily for 3 months of the year,
for 2 or more consecutive years
Wheeze with reduced peak
flow rate

10. Pulmonary Pleuritic or non-pleuritic chest
embolism pain
Haemoptysis
Risk factors for venous thromboembolism present (signs of
DVT commonly absent)
Sudden breathlessness in young
Pneumothorax otherwise fit adult
Breathlessness following invasive procedure e.g
subclavian vein puncture
Pleuritic chest pain
Visceral pleural line on chest x-ray, with absent lung markings between
this line and the chest wall

11. Cardiac
tamponade Raised JVP
Pulsus paradoxus >
20mmHg
Enlarged cardiac silhouette on chest
X-ray
Known carcinoma of bronchus or
breast
Laryngeal History of smoke inhalation or the ingestion of
obstruction corrosives
Palatal or tongue oedema
Anaphylaxis

12. Tracheobronchial Stridor (inspiratory noise) or mnophonic
obstruction wheeze (expiratory 'squeak')
Known carcinoma of the bronchus
History of inhaled foreign body
PaCo2>5 kPa in the absence of chronic
obstructive pulmonary disease
Wheeze unresponsive to bronchodilators

13. Large pleural Distinguished from pulmonary consolidation
effusion on the chest x-ray by:
Shadowing higher laterally than medially
Shadowing does not conform to that of a
lobe or segment
No air bronchogram
Trachea and mediastinum pushed to
opposite side

14. Arterial blood gases and pH in breathlessness with a normal chest X-ray
Disorder PaO2 PaCO2 PHa
Acute asthma Normal/low Low High
May be Normal or
Acute exacerbation of COPD Usually low high low
Normal/low (without pre-existing
Pulmonary embolism cardiopulmonary disease) Low High
Pre-radiological pneumonia Low Low High
Sepsis syndrome Normal/low Low Low
Metabolic acidosis Normal Low Low
Hyperventilation without
organic disease High/normal Low High