Shortness of Breath

  • 2 Nov, 2020
  • Reading time:1 mins read
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FieldsPnuemothorax Pneumonia Pericarditis Pulmonary Emobilsm Pulmonary Oedema / Heartfailure Diabetic Ketoacidosis Acute Coronary Syndromes Panic Attack Asthma COPD 
Age Most common in 20-40y, also seen often in older patients Extremities of age Increases with Age Increases with age Increases with age More common <65 years Increases with Age Most common in 30s-40s, but can occurr at any age Typically <35, first presentation usually <18 > 35 
Gender M > F M = F M > F <55 F > M, >55 M > F M > F F > M M > F F > M M > F in children, F > M after puberty M > F , but prevalence in women increasing 
Typical Presentation A 30 year old male smoker with cystic fibrosis presents to A&E with shortness of breath and sharp chest pain. On examination, there is asymmetric lung expansion, hyperresonance on percussion and decreased tactile vocal fremitus. His breath sounds were reduced on one side. Also classically seen in otherwise fit, young, tall men. A 75 year old woman receiving radiotherapy for oesophageal carcinoma becomes increasingly confused and develops shortness of breath, pleuritic chest pain and a dry cough. O/E she has a temperature of 39’C and she is tachypnoeaic and tachycardic. Chest auscultation suggests a pleural rub A 40 year old man who is known to have had a recent infection with coxsackie virus develops shortness of breath and sharp, pleuritic chest pain which is relieved by leaning forwards. He had rheumatic fever as a child. A 35 year old woman who has recently undergone orthopaedic surgery presents to A&E with acute onset shortness of breath and haemoptysis. O/E she is hypotensive with a raised JVP. She takes no regular medications other than the COCP. A 69 year old man with a family history of heart disease and hypertension develops shortness of breath and increasing intolerance to exercise. He has found that he is being increasingly woken in the night due to difficulty breathing. O/E he has crackles in both lung bases and an S3 heart sound. A 26 year old woman is taken to A&E after becoming increasingly drowsy and confused at work, with diffuse abdominal pain and vomiting. She has been thirsty with polyuria. She has been under the weather the past few days with a cold. An obese 70 year old male with a 40 pack year smoking history and type 2 diabetes mellitus is brought to A&E with shortness of breath and central crushing chest pain which is radiating down the inside of his arm, and into his jaw. A 30 year old woman presents to A&E with shortness of breath, palpitations, chest pain and the belief that she is about to die. O/E she is sweating and trembling. She has a history of anxiety and depression. A 21 year old woman is brought into A&E by her concerned friend with shortness of breath and a dry cough. This began after she had gone for a run in cold weather. She says she has noticed a similar feeling a twice over the past month, and it has woken her in the middle of the night. O/E, there is a wheeze. She has a PMH Of hay fever and occasional eczema. A 50 year old man visits his GP with a 3 month history of shortness of breath and a productive cough. O/E he is tachypnoeaic with a wheeze and signs of cyanosis, and appears to be breathing with pursed lips. He has a 40 pack year smoking history and currently smokes 40 per day. 
Other Symptoms ● Sharp chest pain ● SOB ● Chest tightness ● Cough ● Fatigue ● Reduced AE on affected side ● SOB ● Cough (usually productive in young; dry in eldery) ● Vomiting ● Headache ● Loss of appetite ● Pleuritic chest pain ● Haemoptysis (rarely) ● SOB ● SOB ● Haemoptysis ● Dizziness ● Syncope ● SOB ● Fatigue ● Lethargy ● Exercise intolerance ● Weight loss ● Wheeze ● Nocturnal cough ● Abdominal pain Vomiting ● Polyuria ● Thirst ● Weight loss ● Weakness ● N&V ● Leg cramps ● Blurred vision ● Central crushing chest pain ● May radiate down inside of arm and into neck/ jaw/ epigastrium/ back ●Nausea ●Feeling hot/clammy ● SOB ● Distress ● 'Feeling of impending doom' ● Syncope ● Vomiting ● Confusion ● SOB ● Palpitations ● Feeling of choking ● Chest pain ● Nausea● Dizziness ● Derealisation/ depersonalisation ● Feeling of impending doom ● Numbness/ tingling ● SOB ● Cough (unproductive) ● Chest tightness ● Often worse at night ● SOB ● Cough (productive or non-productive) ● May be chest pain if associated with pneumonia 
Pain Acute, worse in inspiration ('pleuritic') Sub acute onset. Pleuritic. ● Acute ● Sharp, pleuritic chest pain aggravated by movement, exercise and swallowing and relieved by leaning forwards Pleuritic, acute onset, ften felt in the back, less often in the chest Usually painless ● Gradual drowsiness, vomiting and dehydration with diffuse abdominal pain Acute, sudden onset Acute onset. Can be described as central and crushing, like ACS. Maybe sensation of chest tightness. Usually comes on sub-acutely Often none. May be pleuritc chest pain in associated with pneumonia 
Signs ● Tachycardia ● Tachypnoea ● Cyanosis (skin blue etc.) ● Absent breath sounds over affected lung ● Asymmetric lung expansion – mediastinal and tracheal shift to contralateral side in tension pneumothorax ● Hyperresonance on percussion ● Decreased tactile fremitus ● Adventitious lung sounds: ipsilateral crackles, wheezes ● Tracheal deviation (tension pneumothorax - decompress immediately!) ● Fever ● Rigors ● Upper abdominal tenderness if lower lobe pneumonia ● Signs of consolidation ● Dyspnoea ● Tachypnoea ● Tachycardia ● Increased secretions in ventilated patients ● Pleural rub/ rapid shallow breathing (if strep pnuemoniae) ● Confusion in elderly ● Hypotension and AF are complications ● Fever ● Pericardial friction rub ● Pyrexia ● Cyanosis ● Tachypnoea ● Tachycardia ● Hypotension ● Raised JVP ● Pleural rub ● Pleural effusion ● Orthopnea ● Paroxysmal nocturnal dyspnea ● Ascites ● Raised JVP ● Pulsus alternans ● Hypotension ● Tachycardia ● Heaves ● Displaced apex beat ● Gallop (S3) ● Bilateral crepitations ● Cachexia and muscle atrophy ● Hepatic tenderness ●SOB ● Kussmaul breathing ● Clinical evidence of dehydration, e.g. reduced skin turgor ● Hypotension ● Cold extremities/ peripheral cyanosis ● Tachycardia ● Hypothermia ● Increased RR ●Smell of acetone on breath ● Confusion/ drowsiness/ coma ● Sweating ● Tachycardia ● 3rd/4th heart sounds ● Pan systolic murmur ● Pericardial rub ● Pulmonary oedema (crepitations in lungs) ● Hypotension ● Quiet first heart sound ● Narrow pulse pressure ● Raised JVP ● Pallor ● Sweating ● Trembling or shaking ● Cold peripheries ● Wheeze ● In children, look for tracheal tug, intercostal recession ● Tachypnoea ● Use of accessory muscles of respiration ● Hyperinflation ● Cricosternal distance <3cm ● Reduced chest expansion ● Resonant chest sounds ● Quiet breath sounds over areas of emphysematous bullae ● Wheeze ● Cyanosis ● Cor pulmonale ● Prolonged experiation ● Pursed lip breathing ● Weight loss 
Past Medical History ● Tall and thin ● Smoker ● FH ● Underlying lung disease (COPD, cystic fibrosis, pneumonia) ● Mechanical ventilation ● HX previous pneumothorax ● HX trauma ● ● Immunosuppression/ HIV ● Hospital admission ● Recent HX viral infection/ ‘the flu’ ● Smoker ● Alcohol excess ● Bronchiectesis (e.g. in CF) ● Bronchial obstruction (e.g. carcinoma) ● IVDU ● Dysphagia ● HX MI ● Autoimmune disease ● Trauma ● Neoplasm ● Recent viral or bacterial infection ● HX TB/ rheumatic fever ● HIV positive ● FH thrombosis ● Recent stasis/ immobility (in hospital/ long flight) ● Dehydration ● pregnancy ● combined oral contraceptive pill ● Obesity ● Varicose veins ● Recent surgery ● previous DVT/ embolism ● Trauma ● Infection ● Malignancy ● Congestive heart failure ● Recent MI ● Thrombophilia ● Peripheral oedema ● Crackles in lungs ● Hypertension ● Coronary artery disease ● Smoker ● Arrhythmia ● Valvular disease ● Hx of MI/ myocardial ischaemia ● Obesity ● Excessive alcohol consumption ● Cocaine use ● Chemotherapeutic drugs (beta blockers) ● Thyrotoxicosis/ myxedema ●Cardiomyopathy ● Anaemia ● Pulmonary hypertension ● Pericardial disease ● Family history ● New onset UTI/ flu-like illness/ pneumonia ● Hx recent surgery ● Hyperglycaemia ● Diabetes Mellitus – predominantly T1 ● Hx poor control of hyperglycaemia ● Pregnancy ● Stroke ● Cocaine use ● FH IHD / MI ● Smoker ● Hypertension ● Diabetes ● Hyperlipidaemia ● Obesity ● Sedentary lifestyle ● Stress ● Left ventricular hypertrophy ● Cocaine use ● High fibrinogen levels ● Type ‘A’ personality ● IHD ● Previous MI ● HX anxiety or depression ● HX panic attacks ● Interpersonal conflict or loss ● Injury ● Illness ● Use of stimulants (caffeine, decongestants, cocaine, sympathomimetics such as amphetamine, MDMA) ● DH SSRIs recently discontinued ● Obstructive pulmonary disorder ● IBS ● Frequent migraines● OCD ● Phobias ● Known asthmatic ● FH ● Flares with viral infections ● Eczema / atopy ● Drug HX aspirin/ beta blockers/ NSAIDs ● Symptoms in response to allergens ● Exacerbated by smoking ● Childhood HX asthma ● HX skin allergies ● Hay fever ● Occupation: baker, electrician, carpenter, painter, polyurethane contact ● Exacerbated by cold air/ following exercise ● Smoking HX >10 pack years ● Low socioeconomic status ● Low birth weight ● Occupation: coal mining ● FH ● Exacerbated by infection (Streptococcus pneumonia/ Haemophilus influenzae)● Frequent lower respiratory tract infections during childhood 
Bloods ● ABG: low O2 and high CO2 with respiratory acidosis ● Raised WCC ● Raised ESR >100mm/h ● Raised CRP ● Possible anaemia (if abscess) ● Blood cultures to identify organism ● Leukocytosis if resulting from bacterial/ viral infection ● ABG: O2 low, CO2 normal/low +/- metabolic acidosis ●D-dimer ● Anaemia ● Hyponatraemia ● Hypo/hyperkalaemia ● Abnormal LFTs ● Abnormal RFTs ● TFT to rule out thyrotoxicosis/ myxedema ● Hyperglycaemia (but not always!) ● Ketones in blood ● Urinalysis: ketones and blood ● ABG: acidosis ● Urea and creatinine may indicate kidney impairment due to dehydration ● High CRP ● High WCC ● May have high serum amylase ● Cardiac enzyme tests: Troponin T and Troponin I raised. Should be checked at presentation, and subsequently at a later interval (often 6hrs (high sensitivity troponin test) or 12 hours ● Creatine kinase raised ● All normal ● Raised eosinophils ● May be evidence of an exacerbating illness (e.g. pneumonia, or in children, RSV) ● ABG: decreased or increased PaO2; normal / decreased/ increased PaCO2; may be acidotic (may or may nor be fully or partially compensated depending on duration and seveirty) ● Alpha1 antitrypsin deficiency common ● Haematocrit >45 ● Normocytic normochromic anaemia ● Secondary polycythaemia 
Imaging ● CXR: air in pleural space, trachea deviated away from pneumothorax if tension pneumothorax, lung collapse may be visible. (NB - if a tension pneumothorax, you shouldn't be doing a CXR, you should be decompressing immediately based on clinical signs!) ● CXR: consolidation 48h after onset of symptoms ● None specific ● CXR: normal/ pulmonary oedema signs (raised hemidiaphragm) +/- atelectasis ● VQ scan or CT depending on patients age and other factors ● CXR: cardiomegaly and pleural effusions ● Echocardiogram to confirm ● Angiography to assess extent of IHD ● CXR to exclude infection ● CT to exclude stroke if confusion/recurrent vomiting ● CXR: cardiomegaly/ pulmonary oedema/ widened mediastinum ● All normal ● CXR normal/ inflammation during exacerbation ● CXR normal until severe COPD ● In advanced disease, CXR shows: flattened hemidiaphragms, increased chest size, cylindrical heart, focal bullae, hyperinflation (>6 anterior ribs above diaphragm in mid-clavicular line), large central pulmonary arteries, decreased peripheral vascular markings 
Additional Investigations ● None specific ● O2 sats <94% worrying, unless COPD / smoker, then 88-92% acceptable ● Sputum culture ● Urine culture for legionella ● Pleural fluid aspiration ● CURB-65 score for community-acquired pneumonia ● ECG: widespread saddle shaped ST elevation and PR interval depression. Later sign: T wave insertion and ST elevation in inferior and anterior leads ● ECG: Sinus tachycardia, T-wave inversion, new onset AF, right bundle branch block, right axis deviation ● Severe ECG changes: S waves in lead I, Q waves in lead III, T wave inversion in lead III ● Vital capacity decreased by a third of maximum value ● ECG may indicate underlying cause, e.g. MI, BBB, ventricular hypertrophy, pericardial disease, arrhythmia ● Pulmonary function tests to exclude lung disease causing breathlessness ● ECG: STEMI (peaked T wave and ST elevation. Definition: ST elevation of >2mm in at least 2 chest leads, or >1mm in at least 2 other leads)) / NSTEMI (look for other ECG changes, e.g. new LBBB) ● O2 sats: low ● All normal ● PEF ● Spirometry: 15% improvement in FEV1 or PEF following inhalation of bronchodilator ● Carbon monoxide transfer test normal ● Exercise test ● Bronchial (histamine or metacholine) provocation test for airway hyper-responsiveness ● Nitrous oxide raised on breath test ● Skin prick test ● Allergen provocation test ● Histology: thickening of bronchial basement membrane, Curschmann’s spirals and Charcot-Layden crystals ● Spirometry: FEV1: FVC ratio <70% ● FVC <80% predicted ● Increased residual volume ● ECG: right atrial and ventricular hypertrophy suggestive of cor pulmonale, leading to large p waves ● Reduced gas transfer ● Spirometry (>80% in mild disease; <30% in severe disease) ● Histology: neutrophil infiltrate 
Full Article PneumothoraxPneumonia  and  Pneumonia in ChildrenPericarditisDVT and PEHeart FailureDiabetesAcute Coronary SyndromesFear Disorders  and  AnxietyAsthmaCOPD