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The Patient With Breathing Difficulties: Assessment

- Breathlessness is a common medical emergency that requires a structured approach to identify and treat immediately life-threatening causes - Immediately life-threatening causes of breathlessness affect the airway, breathing, or circulation, such as airway obstruction, acute severe asthma, pulmonary edema, tension pneumothorax, acute severe left ventricular failure, dysrhythmia, or pulmonary embolism - The structured approach of assessing the airway, breathing, and circulation can help identify these causes so they can be treated promptly

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76 views5 pages

The Patient With Breathing Difficulties: Assessment

- Breathlessness is a common medical emergency that requires a structured approach to identify and treat immediately life-threatening causes - Immediately life-threatening causes of breathlessness affect the airway, breathing, or circulation, such as airway obstruction, acute severe asthma, pulmonary edema, tension pneumothorax, acute severe left ventricular failure, dysrhythmia, or pulmonary embolism - The structured approach of assessing the airway, breathing, and circulation can help identify these causes so they can be treated promptly

Uploaded by

OccamsRazor
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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THE PATIENT WITH BREATHING DIFFICULTIES

Introduction

Acute breathlessness is a common emergency condition. The effort required for


breathing makes it virtually impossible for the patient to provide any form of medical
history and questioning may only make the situation worse. The clinicians skills will
help to determine the underlying cause and dictate appropriate management.

Immediately life threatening causes of breathlessness

Airway - obstruction

Breathing - acute severe asthma


acute exacerbation of chronic obstructive pulmonary disease
pulmonary oedema
tension pneumothorax

Circulation - acute severe left ventricular failure


dysrhythmia
pulmonary embolus
cardiac tamponade

Keypoint
It is important to remember that the breathless patient does not always have pathology
affecting the respiratory or cardiovascular systems.

Primary Assessment and Resuscitation

Airway

Assessment
This is summarised in the box below.

Summary of airway assessment

Look respiratory - rate


effort
symmetry
Feel expired air
trachea
Listen count to 10
breath sounds
Treatment
High flow oxygen (Fi02 = 0.85) may relieve some of the patients distress. If airway
obstruction is suspected, request immediate review by a specialist. If a foreign body
has been inhaled attempt a Heimlich or modified Heimlich manoeuvre.

Breathing

Assessment
This is summarised in the box.

Summary of breathing assessment

Look colour, sweating


posture
respiratory - rate
effort
symmetry
Feel tracheal position
tracheal tug
chest expansion
Percuss
Listen

Treatment
Irrespective of the underlying cause of the bronchospasm, treat patients with
nebulised bronchodilators whilst clues to the underlying diagnosis are sought.

Immediate management of a tension pneumothorax is needle thoracentesis followed


by intravenous access and then chest drain insertion.

Circulation

Assessment
This is summarised in the box.

Summary of circulatory assessment

Look pallor, sweating, venous pressure


Feel pulse rate, rhythm and character
capillary refill time
blood pressure
apex beat
Listen heart sounds, extra sounds
Treatment
All patients should receive high flow oxygen, be treated in a seated position and have
their oxygen saturation, pulse, blood pressure and cardiac rhythm monitored.
Intravenous access is necessary and at least one large venflon (12-14gauge) is
required in the antecubital fossa.

The management of the shocked patient will depend on the underlying cause.
Treatment options are summarised in the box.

Treatment of shock

Cause Treatment

Acute, severe, left ventricular failure Inotropes

Dysrhythmia - tachycardia Cardioversion


Bradycardia Atropine
Inotropes
Pacing

Hypovolaemia Fluid challenge

Pulmonary embolus Anticoagulation


Thombolysis
Fluids

Sepsis Fluids
Antibiotics
Inotropes

Anaphylaxis Adrenaline
Chlorpheniramine
Hydrocortisone

Cardiac tamponade Fluids


Pericardiocentesis

Once the patients condition is stabilised then further information can be obtained
from the secondary assessment.
Summary

In the breathless patient, the immediately life threatening problems are:

Airway - obstruction
Breathing - acute severe asthma
acute exacerbation of COPD
pulmonary oedema
tension pneumothorax
Circulation - acute severe left ventricular failure
dysrhythmia
dypovolaemia
Pulmonary embolus
cardiac tamponade

These conditions can be identified and differentiated clinically.

All patients require oxygen and intravenous access.

Secondary Assessment

Many patients with breathlessness will be able to give a history, albeit fragmented.
The conditions diagnosed in this assessment phase are shown in the box.

Potentially life threatening causes of breathlessness

Severe asthma
Acute chronic respiratory failure
Pulmonary oedema
Simple pneumothorax
Pneumonia
Pleural effusion
Pulmonary embolus
Metabolic acidosis diabetic ketoacidosis, salicylate overdose
Pontine haemorrhage
SUMMARY

- Breathlessness is a common medical emergency


- The structured approach (airway, breathing and circulation) will ensure that
the immediately life threatening causes are identified and treated

Immediately life threatening causes of breathlessness are:

A similar framework can be applied to non immediately life threatening conditions.

Modified from: Acute Medical Emergencies The Practical Approach (ALS G Group). BMJ Books 2001

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