Breathlessness

 

Breathlessness, also known as dyspnoea, is a subjective, usually distressing sensation or awareness of difficulty with breathing.  Breathlessness can be classified by its speed of onset as:

  1. acute breathlessness — when it develops over minutes
  2. sub-acute breathlessness — when it develops over hours or days
  3. chronic breathlessness — when it develops over weeks or months

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Acute & sub-acute breathlessness

Assessment for emergency admission

  1. Perform an initial Airway, Breathing, Circulation (ABC) assessment
  2. Determine the need for emergency admission by assessing the person's blood pressure, pulse, respiratory rate, temperature, level of consciousness, peak expiratory flow rate (PEFR), oxygen saturation, and (if possible) echocardiogram (ECG)
  3. Arrange emergency admission for people with:
    1. Suspected asthma and any features of severe or a life-threatening acute asthma attack
    2. Clinical features of a pulmonary embolus or pneumothorax
    3. Rapid onset or worsening of symptoms of suspected heart failure
    4. Suspected sepsis
    5. ECG suggesting a cardiac arrhythmia or myocardial infarction
  4. Consider hospital assessment for all people with suspected community-acquired pneumonia and a CRB 65 score > 50
  5. For recommendations on admission criteria for people with an exacerbation of chronic obstructive pulmonary disease (COPD), see COPD for more information

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NOTE Clinical judgement should be used when considering emergency admission for people with an unclear cause of breathlessness.  A low threshold for admission may be required in order to rule out serious causes

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Features associated with presence or risk of serious illness that usually require emergency hospital admission include:

  • Stridor
  • Altered level of consciousness or acute confusion
  • Significant respiratory effort (particularly if the person is becoming exhausted)
  • Elevated respiratory rate
  • Oxygen saturation < 92%
  • Cyanosis
  • Tachycardia
  • Hypotension
  • Peak expiratory flow rate (PEFR) < 50% of predicted
  • Immunosuppression or other significant comorbidity
  • Pregnancy or postnatal period
  • Elderly or very frail people
  • People who are unable to cope at home
  • Poor or deteriorating general condition

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Management (when emergency admission not required)

  1. Take a detailed history and physical examination
  2. Ask about:
    1. Duration, pattern and severity of breathlessness
    2. Symptom change with position, for example, when lying flat (orthopnoea)
    3. Presence of:
      1. Fever
      2. Cough
      3. Chest pain
      4. Palpitations
      5. Wheeze
      6. Any changes to voice
    4. History of conditions such as cardiac or pulmonary disease, venous thromboembolism or anxiety
    5. Pregnancy
    6. Medications, for example, asthma may be exacerbated by beta blockers
  3. Carry out a general, cardiovascular and respiratory examination
  4. Look for clinical features of:
    1. Acute asthma, especially in people with wheeze or cough that is worse at night, or upon exercise or exposure to allergens
    2. An acute exacerbation of chronic obstructive pulmonary disease (COPD), especially in people older than 35 years of age who smoke (or who have smoked) particularly if they have wheeze and a new or worsening cough
    3. Pneumonia, especially in people with a cough and at least one other symptom of sputum, wheeze, fever, or pleuritic pain
    4. Lung/lobar collapse, especially in people with a history of cancer with lymph node involvement, tuberculosis, and inhaled foreign body, or debility causing retained airway secretions
    5. Pleural effusion, especially in people with: heart, liver, or renal failure, cancer, tuberculosis, or pleural infection
    6. Anxiety-related breathlessness, especially in people who have no clinical features of a physical cause for breathlessness
  5. Arrange investigations to confirm a suspected cause, or to identify the cause when the cause is uncertain
  6. Manage the underlying cause of breathlessness for people with:
    1. Acute asthma
    2. Acute exacerbation of COPD
    3. Bronchiectasis
    4. Community-acquired pneumonia
    5. Lung/lobar collapse - refer the person to a respiratory specialist for investigation of the underlying cause
    6. Pleural effusion - refer (or admit) the person, for drainage of the effusion and investigation of the underlying cause
    7. Acute panic attack:
      1. Explain that the person's symptoms are due to anxiety and hyperventilation
      2. Advise the person to try to control their breathing rate (and counting breaths in and out gently), slowing it down
      3. Manage any persistent symptoms of hyperventilation, using a bag to re-breathe expired air
      4. Consider management of any underlying anxiety disorder
  7. For people with acute breathlessness that remains of uncertain cause, reassess for risk factors and clinical features of pulmonary embolism.  Arrange urgent referral for further investigations if pulmonary embolism is suspected

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Chronic breathlessness

Assessment for emergency admission

  1. Perform an initial Airway, Breathing, Circulation (ABC) assessment
  2. Determine the need for emergency admission by assessing the person's blood pressure, pulse, respiratory rate, temperature, level of consciousness, peak expiratory flow rate (PEFR), oxygen saturation, and (if possible) echocardiogram (ECG)
  3. Arrange emergency admission for people with:
    1. Suspected asthma and any features of a severe or life-threatening acute asthma attack
    2. Clinical features of a pulmonary embolus or pneumothorax
    3. Rapid onset or worsening of symptoms of suspected heart failure
    4. Suspected sepsis
    5. ECG suggesting a cardiac arrhythmia or myocardial infarction
  4. Consider hospital assessment for all people with suspected community-acquired pneumonia and a CRB 65 score > 0

.

NOTE Clinical judgement should be used when considering emergency admission for people with an unclear cause of breathlessness.  A low threshold for admission may be required in order to rule out serious causes

.

Features associated with presence or risk of serious illness that generally warrant emergency hospital admission include:

  • Stridor
  • Altered level of consciousness or acute confusion
  • Significant respiratory effort (particularly if the person is becoming exhausted)
  • Elevated respiratory rate
  • Oxygen saturation < 92%
  • Cyanosis
  • Tachycardia
  • Hypotension
  • Peak expiratory flow rate (PEFR) < 50% of predicted
  • Immunosuppression or other significant comorbidity
  • Pregnancy or postnatal period
  • Elderly or very frail people
  • People unable to cope at home
  •  Poor or deteriorating general condition

.

Management (when emergency admission not required)

  1. Take a detailed history and physical examination
  2. Ask about:
    1. Duration, pattern and severity of breathlessness
    2. Symptom change with position, for example, on lying flat (orthopnoea)
    3. Presence of:
      1. Fever
      2. Cough
      3. Chest pain
      4. Palpitations
      5. Wheeze
      6. Any changes to voice
    4. History of conditions such as cardiac or pulmonary disease, venous thromboembolism or anxiety
    5. Pregnancy
    6. Medications, for example, asthma may be exacerbated by beta blockers
  3. Carry out a detailed, cardiovascular and respiratory examination
  4. Look for clinical features of:
    1. Chronic heart failure, especially if the person has a history of ischaemic or valvular heart disease, hypertension, or the onset of chronic cardiac arrhythmias (such as atrial fibrillation)
    2. Asthma, especially in people with episodic wheeze or cough that is worse at night, or upon exercise or exposure to allergens
    3. Chronic obstructive pulmonary disease (COPD), especially in people older than 35 years of age who smoke (or who have smoked), particularly if they have exertional breathlessness, chronic cough, regular sputum production, frequent winter 'bronchitis' or wheeze
    4. Bronchiectasis, especially in non-smokers with chronic progressive breathlessness that is associated with either a chronic productive cough or recurrent chest infections
    5. Interstitial lung disease, especially in people with a history of exposure to asbestos, dust (such as coal dust), birds, hay, or mushrooms
    6. Pleural effusion, especially in people with: heart, liver, or renal failure, cancer, tuberculosis or pleural infection
    7. Abdominal splinting secondary to obesity or ascites
    8. Anaemia
  5. Arrange investigations to confirm the cause of breathlessness
  6. Manage the underlying cause of chronic breathlessness for people with:
    1. Chronic heart failure
    2. Asthma
    3. COPD
    4. Bronchiectasis
    5. Restrictive lung disease - refer the person to a respiratory specialist for assessment and management of the cause
    6. Pleural effusion - refer (or admit) the person, for drainage and investigations of the underlying cause of the effusion
    7. Anaemia
    8. Diaphramatic splinting that is secondary to:
      1. Obesity
      2. Ascites - refer the person to an appropriate specialist for management of the underlying cause
        1. NOTE  women with suspected ascites on examination should be referred urgently (to be seen within 2 weeks) to a gynaecological cancer service to assess for ovarian cancer
  7. For people with chronic breathlessness that remains of uncertain cause, reassess for risk factors and clinical features of pulmonary embolism:
    1. If pulmonary embolism is suspected, arrange urgent referral
    2. If pulmonary embolism seems unlikely, arrange routine referral

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

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Spirometry

In combination with undertaking structured clinical assessment of the patient's signs and symptoms, GPs should carry out quality-assured spirometry.  Spirometry is performed in primary care and must be carried out by suitably trained nurses accredited to ARTP standards.  Please click on the Spirometry map register for a full list of those practices where spirometry is being undertaken to the accredited standard

Further information:

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

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