Breathlessness Station

Presenting Complaint:

Shortness of breath

Brief History:

You are breathless and cannot complete full sentences without having to stop to catch your breath. You are coughing occasionally, bringing up clear sputum.

Onset: Breathlessness for the last few months now but the last couple of days has worsened significantly. Your husband and daughter called the ambulance.

Baseline: You get breathless walking up hills but are normally ok on the flat. This morning you couldn’t even get out of bed.

Exacerbating/Alleviating factors: You struggle on lying flat. This morning you tried taking your blue asthma inhaler but it had no effect.

Other symptoms (if asked): 

• You have been coughing more over the last few days too (mostly dry with some clear sputum, no blood).
• You feel more weak/fatigued than usual.
• Your legs feel swollen.
• No chest pain, fever, headache, dizziness, nausea/vomiting. Passing urine and opening bowels as usual, no pain in legs or abdomen.

Past Medical History (if asked):

Asthma, T2DM, hypertension, hypothyroidism, osteoarthritis.

Drug History:

Qvar inhaler 2 puffs BD. Salbutamol inhaler PRN. Metformin 1000mg BD. Amlodipine 10mg OD. Furosemide 40mg OD. Levothyroxine 75mcg OD.

Allergies:

Penicillin - rash.

ABCDE

Airway

• Patent. 
• No stridor.
• No intervention required.

Breathing

• RR 28, SpO2 86% on air. 
• Not able to talk full sentences without stopping to catch breath. 
• Using accessory muscles (SCM). 
• No tracheal deviation. 
• Equal chest expansion. 
• Dull to percussion throughout. 
• Coarse crackles on auscultation bilaterally. Equal air entry. No wheeze.

Investigations: 

• Request an arterial blood gas (ABG).
• Request a portable chest x-ray.
• Send a sputum sample.

Interventions: 

• Ensure the patient is sat upright.
• Start supplemental oxygen (15L/min via non-rebreather mask) and titrate to response and target saturations. 
• This patient is in respiratory distress and high risk for deterioration - students should state they would ask for the patient to be moved to ED resus as soon as possible. 
• Consider starting salbutamol/ipratropium nebuliser if concerned about asthma exacerbation given PMH.

Circulation

• HR 110. BP 162/96. Core temp 37.4 C. 
• CRT<2s. 
• Regular bounding pulse. 
• HS I+II+0. 
• JVP is elevated. 
• There is peripheral pitting oedema to the legs up to the mid-shin.

Investigations: 

• 12-lead ECG. 
• Bloods - FBC, U&Es, LFTs, CRP, lactate if not already done on ABG, troponin, NT-proBNP, consider D-dimer. 
• Consider request for bedside echo to be done by senior. Once the patient is stable, you can consider a formal transthoracic echo.

Interventions: 

• IV cannulation, at least one wide-bore. 
• No requirement for IV fluids. 
• Recognise signs of fluid overload - start IV loop diuretic e.g. Furosemide/Bumetanide (if already taking orally, generally 1-2x pt usual dose as IV bolus. E.g. Furosemide 40mg-80mg IV bolus in this case). 
• IV diuretics should prompt urinary catheter insertion for monitoring and patient comfort (especially when the patient may be too breathless to mobilise to the bathroom regularly).

Disability

• Alert. 
• GCS 15. 
• CBG 5.8mmol/L. 
• PEARL 4mm. 
• No abnormal neurological signs.
• No intervention required.

Exposure

• Full inspection - there are no signs of bleeding, wounds, rashes, bruises, erythema, tenderness, needle track marks, medication patches etc. 
• There is bilateral pitting oedema of the lower legs up to the mid-shin. 
• Calves are soft and non-tender. 
• Abdomen is soft and non-tender.
• No intervention required.

Re-assessment

A - Patent

B - RR 20. SpO2 95% on 15 L/min. Speaking a full sentence between breaths but still very breathless. Patient moved to ED resus.

C - HR 98. BP 156/94. Started IV furosemide.

D - Alert. No change.

E - Bilateral pitting oedema. No change.

Examiner questions

1. Please interpret the following investigations:

Answer:

- In keeping with a metabolic acidaemia (low pH and HCO3, low base excess, raised lactate)

- T1 respiratory failure (low PO2 and saturations, normal/low PCO2)

- Electrolytes grossly normal

Answer:

- AP erect CXR of Carol Barton

- Bilateral diffuse patchy consolidation in keeping with pulmonary oedema in the clinical context of fluid overload here

- Presence of other classical features of pulmonary oedema: Bilateral perihilar shadowing (Batwing appearance); left pleural effusion, upper lobe diversion, Kerley B lines 

- AP film however evidence of possible cardiomegaly

- No gross bony injury, leads noted crossing film

Answer: 

- Sinus tachycardia, regular, approx 100 bpm.

- ECG changes in keeping with suspected heart failure: Left axis deviation, voltage criteria in keeping with Left Ventricular Hypertrophy (S wave in V1 and R wave in V5-6 >35mm).

- Mild ST-elevation more likely related to LVH than ACS.

- Some T-wave inversion noted in lateral leads V4-6, AVL, I. These findings can also be associated with LVH, however should check if they are new compared to older traces.

- Narrow RSR’ pattern in V3.

Answer:

- Raised NT-proBNP raises suspicion for heart failure, in keeping with clinical and radiological features of heart failure and pulmonary oedema.

- Normal inflammatory markers (WBC, CRP) making infectious aetiology unlikely.

- Low troponin effectively ruling out MI.

- Low D-dimer effectively ruling out PE.

- Very mild anaemia, transfusion not required at present.

- Mildly elevated ALT and ALP likely not of high clinical significance, possibly be related to hepatic congestion.

- Slightly reduced renal function, would ideally compare to previous to determine baseline.

2. Provide some differential diagnoses for this patient with your reasoning for why each is more/less likely.

• Acute heart failure - breathlessness worse on lying flat, hypoxic, coarse crackles, pitting oedema and signs of fluid overload, pulmonary oedema on CXR, raised BNP
• Asthma exacerbation - breathless/hypoxia, would typically hear wheeze, CXR findings often only in infective exacerbation, response to bronchodilators. Fluid overload is not typically a significant feature in asthma and points towards another aetiology
• Pneumonia - breathlessness, hypoxia, chest crackles, would more likely have productive cough, fever, focal consolidation on CXR and raised inflammatory markers
• PE - breathlessness/hypoxia, may have pleuritic chest pain, usually no CXR findings, risk factors for VTE (Virchow’s triad), raised D-dimer

3. Provide a handover of the case using the SBAR format from yourself in ED to the relevant specialty

Example answer:

S. “Hello my name is …, I am calling from the Emergency Department. I have a patient, Carol Barton, with suspected acute decompensated heart failure.

B. The patient is a 79 year old female admitted with worsening breathlessness over the last few months and significant deterioration in the last 2 days. This is worse when lying flat, and does not improve with her asthma medication. She has a background of asthma, hypertension, type 2 diabetes and hypothyroidism.

A. On admission, she was alert, but hypoxic, tachypnoeic, hypertensive and tachycardic. She had coarse crackles to auscultation and bilateral pitting oedema to the mid-shins. A chest x-ray showed diffuse congestion consistent with pulmonary oedema. An ABG showed metabolic acidosis with partial respiratory compensation. Her ECG shows sinus tachycardia with left ventricular hypertrophy. She is saturating 95% on 15L supplementary oxygen. Bloods show raised BNP at 920. We have started IV furosemide.

R. Can you please come to review this patient further in ED with a view to taking over her care?”

4. How would you escalate treatment further in ED if this patient did not respond to supplementary oxygen (i.e. saturations remain low and still in respiratory distress)?

Key points:

• Obtain a senior review / call for help for further support as this patient is continuing to deteriorate, and consider a referral for ITU/Critical care to review

• Seek an urgent specialty review (in this case from Cardiology)

• Repeat ABG on 15L/min O2 - monitor blood PO2/CO2 and pH level for worsening acidosis/hypoxia/failure to compensate

• Consider vasodilator medications to support end-organ perfusion and reduce preload and/or afterload on heart e.g. GTN infusion

• Consider non-invasive ventilation (NIV) such as CPAP or BiPAP to support ventilation and delivery of oxygen

• Consider high flow nasal oxygen if further oxygen titration required

• Ultrafiltration dialysis for fluid offloading in refractory cases with diuretic resistance