Red flag symptoms: Breathlessness

Dr Tillmann Jacobi considers the management of a patient experiencing breathlessness.

Breathlessness is the unsettling sensation of not being able to take in enough air. It can be due to one specific cause or have multiple aetiologies.

Often, breathlessness is an exacerbation or complication of a pre-existing condition.

The speed of onset and additional symptoms can be useful clues to the diagnosis. Distinguish between a problem of the upper or lower airway, or other non-respiratory causes.

Red flag symptoms

  • Sudden onset
  • Inspiratory or expiratory breathlessness
  • Wheeze or stridor
  • Chest pain
  • Drowsiness or agitation
  • Fever

Assessment
The patient is likely to be anxious so aim to reassure them. Ensure that there is a patent airway, that the patient is responsive and that there is no immediate danger.

A nebuliser helps with asthma (COLIN CUTHBERT / Spl)

A brief history should then be sought. Watch the apparent use of any accessory muscles and the pattern of breathing. As a rule of thumb, persistent cough, hoarse or altered speech or a problem with inspiration indicates an upper airway problem; difficulty with expiration indicates lower airway pathology.

Check for fever, cyanosis, abnormal pulse (tachycardia or marked bradycardia are both causes for concern).

Pulse oximetry, if available, can give very useful objective information, and precise respiratory rate is a useful and simple test to perform.

When you auscultate the heart and lung fields listen for normal air entry, effusions, wheeze, crackles, rubs or arrhythmia. Take a peak expiratory flow rate measurement if possible.

Also look for oedema or urticaria, and consider checking the jugular venous pressure. Don't forget to notice characteristic smells that alert to possible toxic or metabolic causes. Look for parasthesia and carpopedal spasm (hyperventilation).

Management
Decide early if the patient needs a referral or if an emergency ambulance is required.

Have a low threshold for referral if the patient is unwell, if there are significantly abnormal findings or multiple problems.

Also consider the social circumstances (whether the patient is elderly, isolated and vulnerable). If there is no apparent acute emergency consider further investigations (ECG, chest X-ray, bloods, sputum).

Treatment depends on the suspected cause. Oxygen should be given, with diuretics for heart failure or with a nebuliser and steroids for asthma or COPD.

Antibiotics or antihistamines plus adrenaline should be given for infections or allergic reactions, respectively. Glyceryl trinitrate, diamorphine and aspirin for angina. Rebreathing in a paper bag +/- beta-blocker for hyperventilation.

Steam may be appropriate for upper airway congestion. Ensure appropriate follow up and safety net accordingly.

Possible causes
  • Respiratory - cystic fibrosis, asthma, COPD, pneumothorax, pleural effusions, pulmonary oedema.
  • Cardiovascular - congenital structural, acute MI or LVF, pulmonary embolism.
  • Infective - epiglottitis or bronchiolitis in children.
  • Obstructive - foreign bodies, secretions, malignancies, vocal cord palsy, increased intra-abdominal pressure - eg ascites.
  • Traumatic - chest trauma, upper airway trauma.
  • Metabolic/immunological - diabetic crisis, anaphylaxis, drug related, severe anaemia.
  • Functional - hyperventilation, emotional, neuromuscular.
  • Dr Jacobi is a salaried GP in York

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