Breathlessness in the Emergency Department

1. Breathlessness in the Emergency Department Dr Orlaith Scullion 11/09/15

2. Dyspnoea in the Emergency Department • Aims • To consider common presentations of dyspnoea in adults presenting to the ED • To describe appropriate initial management and treatment • To identify patients with severe or life threatening conditions • To recognise when to involve ICU

3. BTS Guidelines - CAP • Community aquired • No pre-disposing conditions eg. cancer, immunosuppression • Does NOT apply to those with non-pneumonic LRTI eg. acute exacerbations of COPD / chest infections without CXR changes BTS guidelines for the management of community acquired pneumonia in adults. Thorax 2001:56;iv1-iv64

4. BTS Guidelines - pathogens • S pneumoniae • H influenzae • Legionella spp • S aureus • M catarrhalis • Gram negitive enteric bacilli • M pneumoniae • C pneumoniae • C psittaci • All viruses • Influenza A and B • mixed

5. BTS Guidelines – Clinical and Radiological Features • Not able to predict aetiological agent from clinical / radiological features • Elderly patients are more likely to present with non-specific symptoms and less likely to have fever than younger patients • Radiological resolution often lags behind clinical improvement • Radiological changes caused by atypical pathogens clear more quickly than bacterial pathogens

6. BTS Guidelines • Investigations (Community Rx) • CXR not necessary • SaO2 • Microbiology not recommended, mycobacterium tuberculosis and Legionella if indicated • Investigations (Hospitalise Rx) • CXR / FBC / U+E / LFT / CRP / oxygenation • Blood culture and other microbiology as indicated eg. sputum, urine, serology

7. BTS Guidelines - severity • Confusion (abb MSE 8 or less) • Urea > 7 mmol/l • Resp rate ≥ 30/min • BP > 90 systolic and / or ≥ 60 diastolic • Pre-existing: • Age ≥ 50 • Co-existing disease

8. CURB-65 • Confusion (abb MSE 8 or less) • Urea > 7 mmol/l • Resp rate ≥ 30/min • BP > 90 systolic and / or ≥ 60 diastolic • Age ≥ 65

9. AAH Antimicrobial Guidelines • CURB-65 score • Rountine investigations for all RTI • FBC / CRP / Blood cultures (x2) / CXR / oximetry • Additional investigations when CURB-65 >3 • Urinary antigen for Streptococcus pneumoniae and Legionella sp. / atypical pneumonia and Legionella serology / ABG

10. CURB-65 = 0 or 1 • Not severe • Consider discharge and home treatment • 1st: amoxicillin 500mg – 1g TID oral 7/7 • Alt: clarithromycin or doxycycline

11. CURB-65 = 2 • Not severe • Consider hospital supervised treatment • 1st: amoxicillin 500mg – 1g TID oral 7/7 • Alt: clarithromycin or doxycycline

12. CURB-65 = 3 • Severe • Inpatient treatment • 1st: amoxicillin 1g TID IV plus clarithromycin 500mg BD IV 7/7 • Alt: teicoplanin plus clarithromycin IV

13. CURB-65 = 4 or 5 • Very severe • Assess for ICU admission • 1st: co-amoxiclav 1.2g TID IV plus clarithromycin 500mg BD IV 7/7 • Alt: discuss with microbiology / ICU

14. Aspiration CAP • 1st: amoxicillin 500mg – 1g TID IV plus metrondiazole 500mg TID IV • Alt: clarithromycin plus metrondiazole

15. Managing Exacerbations of COPD Further Reading: NICE guideline 101 COPD in primary and secondary care 2010 • Treat in hospital: • Unable to cope at home / living alone • Severe breathlessness • Deteriorating / poor general condition • Cyanosis • Worsening peripheral oedema • Impaired level of consciousness / acute confusion • Already receiving LTOT • Significant co-morbidities • Significant CXR changes • Sats < 90%, pH < 7.35 PaO2 <7

16. Initial Management • Nebulisers: Salbutamol and ipratropium • Oxygen to maintain sats 92% • Antibiotics if purulent sputum or pneumonic changes on CXR: clarithromycin 500mg oral / iv +/- co-amoxiclav 1.2g iv • Steriods: prednisolone 30mg daily (100mg hydrocortisone iv)

17. Further Management • Consider iv aminophylline • Magnesium 2g iv (not in guideline) • NIV if persistent hypercapnic ventilatory failure despite optimal medical treatment (MAU) • IPPV (ICU) • Chest physio to help clear secretions

18. Severe Asthma in Adults • Moderate • ↑ symptoms • PEF >50-75% best or predicted • Severe • PEF 33-50% best or predicted • RR ≥ 25 / min • HR ≥ 110 / min • Inability to complete full sentences in one breath

19. Severe Asthma in Adults • Life threatening • PEF < 33% best or predicted • SpO2 < 92% • PaO2 < 8 kPa • normal PaCO2 • Silent chest • Cyanosis • Poor respiratory effort • Arrhythmia • Exhaustion, altered conscious level.

20. Treatment of Acute Asthma • Admit if signs of life threatening asthma • Admit if persistent signs of severe asthma after initial treatment • Pts whose PEF > 75% best or predicted one hr after treatment may be d/c home from ED unless other reasons for admission

21. Treatment of Acute Asthma • Oxygen (sats 94 – 98%) • B2 agonists: • Nebulised salbutamol 5mg (oxygen driven) stat • ? Need for continuous nebs • IV if not able to tolerate nebuliser • Ipratropium 500mcg neb 4-6 hrly • Steroids: 40 – 50 mg prednisolone • Magnesium 2g iv over 20 mins • Routine antibiotics not indicated

22. Referral to ICU • Requiring ventilatory support • Acute severe or life threatening asthma failing to respond to therapy • Deteriorating PEF • Persisting / worsening hypoxia • Hypercapnea • Resp acidosis • Exhaustion / poor resp effort • ↓ GCS or confusion • Resp arrest

23. Summary • BTS guidelines • Good initial assessment with obs • Treat appropriately • Get senior help early • Consider ICU

24. Pneumothorax • the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung. Symtoms • Pleuritic Chest Pain • SOB • Decreased exercise tolerance • Cough • Palpitations

25. Signs • Decreased expansion on affected side • Hyper-resonant percussion note • Tachycardia Tension Pneumothorax • Cyanosis • Displaced Trachea • Distended neck veins

26. Management pg 97 Handbook • Page 97 of handbook

27. Chest Drain Insertion • Not required for most patients • Should only be performed under guidance from experienced ED staff • Use the triangle of safety

28. Acute Cardiogenic Pulmonary Oedema • Cardiogenic (or hydrostatic) pulmonary oedema caused by an elevated pulmonary capillary pressure from left-sided heart failure • Most commonly due to an acute ischaemic event • Other causes include acute AR, MR, Tamponade, RAS, AKI • Iatrogenic

29. Signs • Acutely dyspnoeic • Sweaty • Distressed/ agitated • Cough with frothy sputum • Tachycardia • Elevated JVP • Widespread crackles throughout chest

30. Management • ABC apply 02 • ECG if acute STEMI refer for PCI give frusemide • Bloods including TnT ABG BNP • Drugs-Frusemide, Nitrate infusion ?Low dose diamorphine, • Consider CPAP

31. ICU • If patient not responding to treatment persistant severe hypoxaemia despite CPAP and appropriate medical management • Need for Ultrafiltration • Periarrest • Ensure Cardiology team also involved

32. Pulmonary Embolism • Pulmonary embolism is a condition in which one or more emboli, usually arising from a blood clot formed in the veins (or, rarely, in the right heart), are lodged in and obstruct the pulmonary arterial system. • This results in reduced gas exchange of the affected lung tissue, causing hypoxaemia and a reduction in cardiac output. • Large or multiple emboli may result in hypotension, syncope, shock, and sudden death.

33. Signs and Symptoms • Pleuritic chest pain • Shortness of breath • Palpitations • Leg swelling • Dizziness • Collapse

34. Management Suspect PE Examination Wells Score-high(>6) CTPA Med/low -D-dimer: if elevated CTPA Treatment dose enoxaparin unless contraindicated. PESI score to decide if suitable for outpatient management If score greater than 85 admit medically. If negative find alternative diagnosis

35. Lifethreatening PE • Call senior ED staff • Associated with collapse • Severe hypoxia • Lifethreatening arrhythmia • Severe Hypotension despite fluid resuscitation • Call ICU team • Alteplase 50mg thrombolysis

36. Any Questions?..