Approach to patient with difficult in breathing

Shortness of breath or breathlessness may result from a range of pulmonary, cardiac and central nervous system causes. It is important to look for the underlying cause for immediate intervention.

Clinical presentation

• Increased work of breathing

• Altered mental status

• Diaphoresis

• Additional souds - stridor, wheezes

Differential diagnosis

• Pulmonary embolism

• Pulmonary oedema

• Myocardial infarction

• Asthma

• Anaphylaxis

• Airway obstruction

• Tension pneumothorax

• Cardiac tamponade

• Acute chest syndrome

• Pneumonia

• Pericarditis

Investigations

• Blood gases

• Serum Electrolytes

• Serum Creatinine and Urea

• Troponins

• Chest X-ray

• POC ECG

• Bedside Ultrasound

• Lactate

• Troponin

• Random blood glucose

Non-pharmacological treatment

• Perform both primary survey (ABCs) and secondary survey and provide necessary interventions

• Obtain Vital signs

• Position the patient

• Give Oxygen if hypoxic or increased work of breathing

Pharmacological treatment

Pharmacological management will depend on the underlying cause of difficulty in breathing.

(Refer Asthma-respiratory chapter and Acute chest syndrome and Pulmonary embolism-hematology chapter)

1.Anaphylaxis

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction characterised by rapidly developing life-threatening airway (pharyngeal or laryngeal edema) and/or breathing (bronchospasm and tachypnea) and/or circulation (hypotension and tachycardia) problems usually associated with skin and mucosal changes.

Clinical presentation

• Hives

• Angioedema

• Wheezes

• Difficult breathing

• Diarrhoea

• Hypotension

Anaphylaxis is a clinical diagnosis and should be suspected when:

• Acute onset involving skin, mucosal tissue with either respiratory compromization or blood pressure reduction (or syncope)

• Hypotension after exposure to a known allergy for the patient (SBP <90mmHg or >30% from baseline)

• Respiratory compromise (i.e dyspnoea, stridor, wheeze, hypoxemia)

• Exposure to a likely allergen causing involvement of the skin, mucosal, respiratory compromization or blood pressure reduction

Investigations

• Blood gases

• Serum Electrolytes

• POC ECG

• Troponin

• CXR

• POC USS

Non-pharmacological management

• Perform both primary and secondary assessment. If patient has signs of severe respiratory distress perform early intubation/surgical airway

• Give oxygen if hypoxic (spO₂ below 95%) or severe respiratory distress

• Insert TWO large bore IV cannulas or obtain intraoseous access

Pharmacological management

A: adrenaline (IM): Adult 0.3-0.5mg (maximum 0.5mg) every 5-15min as soon as possible. If inadequate response, start adrenaline (IV) 2-10mcg/min in 0.9% sodium chloride (IV)

OR

Ringer lactate (IV) 1-2 litres. If hypotensive. Repeat IV fluids as needed.

Paediatric 0.01mg/kg, every 5-15min as soon as possible. If inadequate response, start adrenaline (IV) 0.05-1mcg/kg/min in 0.9% sodium chloride (IV)

OR

compound sodium lactate (IV) 20mls/kg if hypotensive. Repeat IV fluids as needed.

OR

A: hydrocortisone (IV) 200mg stat

OR

B: salbutamol (nebulisation) 10mg and equal volume of water for injection (This is useful to patients with refractory bronchospasm).

OR

D: methylprednisolone (IV) 1-2mg/kg/day

Disposition

All patient with severe and moderate symptoms which required repeated doses of adrenaline or didn’t respond to treatment must be admitted or referred to higher health facility.

Those with mild response which responded to IM adrenaline may be discharged after 4 hours’ observation at the health facility.