Breathlessness

BMJ learning
Question 1
A. Give back to back salbutamol
A 24 year old woman presents with wheeze and and ipratropium administered
breathlessness to the emergency department. She is via nebuliser and oral
known to have asthma, and has two inhalers from her GP prednisolone, and reassess in
(beclometasone and salbutamol). She has been using her
salbutamol inhaler multiple times per day in the last few one hour
days without relief. Her normal best peak flow is 480 B. Arterial blood gas
l/min. She smokes five cigarettes/day.
On examination she is talking in broken sentences.
C. Chest X-ray
Peak Flow: 180 l/min (37.5% of best peak flow) D. Give back to back salbutamol
Oxygen saturations: 98% on air administered via nebuliser,
Respiratory rate: 28 breaths per minute intravenous hydrocortisone and
intravenous magnesium and
She has bilateral wheeze with poor air entry on chest
auscultation. She is using accessory muscles of breathing. admit to medical high
There are no signs of altered consciousness, exhaustion, dependency unit
arrhythmia, hypotension, or cyanosis. E. Discharge with oral
What would be the first step in your management plan? corticosteroids and smoking
cessation advice
Question 2
A 48 year old woman presents to the emergency
department with a 48 hour history of productive
cough, fever and breathlessness. She has a
history of hypertension, her only medication is
lisinopril and she has no known drug allergies.

Temperature: 38.1°C
BP: 135/90 mmHg
Pulse: 95 bpm
Respiratory rate: 18 breaths per minute
Saturations: 93% on air
Abbreviated mental test score (AMTS) 10/10
She has crackles at her right lung base.
Otherwise systemic examination is normal
Question 2
A. ABG and review from
A 48 year old woman presents to the emergency
department with a 48 hour history of productive HDU team
cough, fever and breathlessness. She has a history of
hypertension, her only medication is lisinopril and B. Discharge with 5 day
she has no known drug allergies. course of amoxicillin
Temperature: 38.1°C C. Admit for IV antibiotics
BP: 135/90 mmHg
D. Arrange for CTPA
Pulse: 95 bpm
Respiratory rate: 18 breaths per minute E. Discharge with 7 day
Saturations: 93% on air course of co-amoxiclav
Abbreviated mental test score (AMTS) 10/10
and clarithromycin
She has crackles at her right lung base. Otherwise
systemic examination is normal

What is the most appropriate course of action?

Question 3
You are reviewing a 76 year old lady who has a diagnosis of
A. Digoxin
heart failure, in the outpatient clinic. She reports that her
exercise tolerance has reduced since her last clinic B. Hydralazine in
appointment three months ago, and she feels much more
tired. combination with
PMH: hypertension, hypercholesterolaemia, and nitrate
osteoporosis.
Meds: ramipril, bisoprolol, furosemide, atorvastatin,
cholecalciferol, and alendronic acid. She is taking maximum
C. Ivabradine
tolerated doses of ramipril and bisoprolol.
O/E: Pitting oedema of both ankles. She has equal bilateral air
D. Losartan
entry and normal heart sounds. Her blood pressure is 122/78
mmHg and her pulse is 58 beats per minute and regular. E. Spironolactone
She had a transthoracic echocardiogram one week before her
appointment. This showed a left ventricular ejection fraction
of 30%. You arrange some blood tests which confirm that her
full blood count and urea and electrolytes are within the
normal range.

What treatment would you offer her next?

Question 4
A 70 year old man with COPD is
admitted with sudden onset right-
sided chest pain and breathlessness.
He smokes 30 cigarettes per day, and
takes regular daily tiotropium, and
salbutamol inhaler as required.
On examination he has a respiratory
rate of 24. His oxygen saturations are
90% on air. He has reduced air entry
on the right hemithorax.
Chest x ray reveals a 3 cm
pneumothorax.
Question 4
A 70 year old man with COPD is A. Discharge and review in
admitted with sudden onset right- outpatient clinic in 2 to 4
sided chest pain and breathlessness. weeks
He smokes 30 cigarettes per day, and
takes regular daily tiotropium, and B. Insert chest drain and
salbutamol inhaler as required. admit to hospital
On examination he has a respiratory C. Therapeutic needle
rate of 24. His oxygen saturations are aspiration
90% on air. He has reduced air entry D. Admit, high flow oxygen,
on the right hemithorax.
and observe for 24 hours
Chest x ray reveals a 3 cm
E. Large bore chest drain
pneumothorax.
insertion and thoracic
What would be the appropriate surgery referral
initial management strategy?
• Types of pneumothorax include :
• Traumatic (secondary to chest trauma)
• Spontaneous
• Primary: occurring in otherwise healthy people (incidence 18 to 28 in 100,000
cases per year for men and 1.2 to six in 100,000 per year for women)
Secondary: occurring in people with pre-existing lung disease. The
consequences of pneumothorax in this group are greater, due to an inability
to tolerate hypoxia, and the management is more complicated.
Tension pneumothorax
• Tension pneumothorax is an immediate life threatening emergency. Correct management is emergency
decompression using a large bore cannula or, if available, a needle thoracostomy device. The cannula
should be inserted on the side of the pneumothorax.
• Suitable sites for needle decompression are the second intercostal space in the midclavicular line, the
fourth intercostal space between the anterior axillary and mid axillary lines, and the fifth intercostal
space between the anterior axillary and mid axillary lines. Imaging should not be required to confirm
this condition. There is rarely time to obtain a chest x ray, and even if obtained it is usually unhelpful, as
size or the presence of mediastinal displacement correlates poorly with the presence of tension within
the pneumothorax.
• A chest drain should always be inserted following needle decompression, and the needle should be left
in place until chest drain is secured. In patients with a larger physical build, a standard cannula may not
always be long enough to penetrate into the pleural cavity in the second intercostal space, so that an
urgent chest drain insertion is needed as an initial procedure.
• You should ensure that a change in the patient’s condition leads to further ABCDE assessments.
Reversible pathologies identified during this process should be treated immediately to prevent further
deterioration and cardiac arrest.
Question 5
A 76 year old man has been admitted on A. Back to back nebulisers
the medical take with a COPD
exacerbation and has been treated with B. Repeat CXR
regular nebulisers, oxygen and
corticosteroids. You have been asked to
C. Commence non-
review him on the second day of his invasive ventilation
admission as he does not seem to be D. Aminophylline infusion
improving.
You assess him and find him to be alert E. Increase O2 to target
but he appears tired. He has a respiratory saturations of 88 to
rate of 28. His oxygen saturations are 84% 92% and obtain an ABG
on 24% oxygen. He has bilateral wheeze
on chest auscultation.
What is the next appropriate step in
management?
Risk factors for pulmonary embolism