M Woollard, I Greaves

The ABC of ommunity emergeny are 4 SHORTNESS OF BREATH M Woollard, I Greaves 341 S Emerg Med J 2004; 21:341 350. doi: 10.1136/emj.2004.014878 hortness of breath is the hief omplaint for about 8% of 999 alls to the ambulane servie, and is the third most ommon type of emergeny all. It an also be an important symptom in patients with a wide range of onditions. Referene should therefore be made to other relevant artiles partiularly that disussing hest pain. The onditions overed in this paper inlude asthma, hroni obstrutive pulmonary disease, aute pulmonary oedema, and hest infetions. The objetives for this paper are listed in box 1. Box 1 Artile objetives To onsider the auses of breathlessness To desribe the reognition of primary survey positive patients and treatment of immediately life threatening problems To desribe the reognition and treatment of primary survey negative patients requiring immediate hospital admission To desribe the findings and treatment of primary survey negative patients suggesting delayed admission, treatment and referral, or treatment and disharge may be appropriate To onsider a list of differential diagnoses. The ommon auses of shortness of breath are asthma, hroni obstrutive pulmonary disease, and pulmonary oedema but there are many other onditions that an pose diagnosti problems (box 2). PRIMARY See end of artile for authors affiliations Correspondene to: Mr M Woollard, The James Cook University Hospital, Department of Aademi Emergeny Mediine, Eduation Centre, Marton Road, Middlesbrough TS4 3BW, UK; Malolm. woollard@ukgateway.net Box 2 Causes of breathlessness Very ommon Asthma Chroni obstrutive pulmonary disease Pulmonary oedema attributable to left ventriular failure Common Pneumonia Pneumothorax Pulmonary embolus Pleural effusion Pregnany Rare Metaboli aidosis Aspirin poisoning Renal failure SURVEY POSITIVE PATIENTS Reognition Patients with a life threatening respiratory emergeny will present in either respiratory failure or respiratory distress. Patients with respiratory distress are still able to ompensate for the effets of their illness, and urgent treatment may prevent their further deterioration. They present with signs and symptoms indiating inreased work of breathing but findings suggesting systemi effets of hypoxia or hyperapnia will be limited or absent. Conversely, patients with respiratory failure may have limited evidene of inreased work of breathing as they beome too exhausted to ompensate. The systemi effets of hypoxia and hyperapnia will be partiularly evident in this group and immediate treatment will be required to prevent ardia arrest. The key findings of primary survey positive patients with shortness of breath are presented in box 3. www.emjonline.om

342 Box 3 Reognition of the primary survey positive patient with shortness of breath Inreased work of breathing Stridor assoiated with other key findings Use of aessory musles Need to sit upright Traheal tug Interostal reession Expiratory wheeze assoiated with other key findings Cessation of expiratory wheeze without improvement in ondition Inability to speak in whole sentenes Systemi effets of inadequate respiration Respiratory rate,10 or.29 Weak respiratory effort Dereased, asymmetrial, or absent breath sounds Oxygen saturation,92% on air or,95% on high onentration oxygen PEFR,33% of normal Hyperapnia (measured with end tidal CO 2 monitor) Tahyardia (>120) or bradyardia (late and ominous finding) Arrhythmias Pallor and/or yanosis (partiularly entral yanosis) Cool lammy skin Falling blood pressure (late and ominous finding) Changed mental status onfusion, feeling of impending doom, ombativeness Falling level of onsiousness Exhaustion (+/2musular hest pain) Box 4 Treatment for primary survey positive patients Treatment before transportation Seure the airway (in moribund patients it may be neessary to esalate rapidly through manual methods, simple adjunts, intubation, and riothyroidotomy until airway seured) High onentration oxygen via non-rebreathing mask (onsider titrating onentration to a COPD patient s normal SpO 21 ) Assist ventilations if respiratory rate,10 or.29, titrated to SpO 2 Nebulised b 2 agonist in the presene of wheeze (for example, salbutamol 5 mg initially) Nebulised antiholinergi in the presene of asthma or COPD (for example, ipratropium bromide 0.5 mg, may be mixed with salbutamol) IM adrenaline in the presene of anaphylaxis (see shok artile) Deompress tension pneumothorax Consider MI/aute oronary syndrome: if present onsider nitrates, aspirin, morphine and onsider thrombolysis and heparinisation (see hest pain artile) Treatment during transportation In addition to the above, onsider: Further nebulised b 2 bronhodilators (no maximum dose for salbutamol) IV fluids (asthma and anaphylaxis) Intravenous or oral ortiosteroids (asthma and anaphylaxis) Antihistamines (anaphylaxis) Cessation of wheeze in a patient with severe asthma may be misinterpreted as an improvement in the patients ondition Cyanosis may be deteted in patients with inreased skin pigmentation by examining the inside of the mouth and eyelids Treatment If it is not possible to obtain an airway, if the patient s ondition is deteriorating rapidly, or they show signs of signifiant respiratory failure (in partiular failure to maintain SpO 2 of 95% on high onentration oxygen) onsider immediate transportation to a hospital with appropriate failities. Important treatment points for primary survey positive patients are listed in box 4. PRIMARY SURVEY NEGATIVE PATIENTS WITH NEED FOR HOSPITAL ATTENDANCE Primary survey negative patients with the findings listed in box 5 who do not respond to prehospital treatment will require hospital admission. If the patient is unable to tolerate a nebuliser, administer 10 25 puffs of b 2 agonist (for example, salbutamol 1.0 to 2.5 mg) from the patients own inhaler via a large volume spaer, whih an be improvised if neessary (fig 1) treatment of life threatening problems. For primary survey negative patients requiring hospital are the seondary survey may be undertaken during transportation. For the remaining patient population a seondary survey may be undertaken at the point of ontat and will ontribute to the deision to admit, treat and refer, or treat and leave. SECONDARY SURVEY The SOAPC system should be used to undertake a seondary survey (see artile 2 of this series). In primary survey positive patients, a seondary survey may not be ompleted in the prehospital phase of treatment as the fous must be on Figure 1 bottle. Improvised large volume spaer using plasti soft drinks www.emjonline.om

Box 5 Diagnosti riteria for primary survey negative patients requiring hospital admission Findings (not reversed by initial treatment) suggesting need for hospital admission Inspiratory or expiratory noises (stridor or wheeze) audible without the aid of a stethosope Cannot speak in whole sentenes Respiration >25 breath/min Pulse >110 beat/min Supplemental oxygen required to maintain SpO 2 at 95% or above (or at usual level of SpO 2 for COPD patients) PEFR,50% of normal Inability to rule out MI or aute oronary syndrome Lak of arer support for those patients unable to look after themselves Rrepeated pratie attempts to measure maximum PEFR an worsen bronhospasm. Limit measurement to best of three fored exhalations 343 Subjetive assessment Confirm that the hief omplaint is shortness of breath. Remember that this may be a symptom of onditions affeting systems other than the hest (for example, hypovolaemia attributable to bleeding). Determine if this is a new problem or an exaerbation of a hroni ondition. Ask what preipitated the problem and what, if anything, makes the patient feel more or less breathless. Ask about assoiated symptoms, suh as hest pain, ough and sputum prodution, palpitations, fever and malaise, and leg pain or swelling. Has the patient been using inhalers or nebulisers more than normal? Have they reently sought other medial assistane? Inquire about previous similar episodes. If this has ourred before, find out what treatment led to its resolution. Has the patient been hospitalised previously for this ondition? What is their general previous medial history? What mediations are they urrently taking, and why? Is there a family history of respiratory illness or heart disease? Finally, investigate the patient s soial irumstanes. Is there evidene of self neglet? If the patient is not apable of aring for themselves, is there adequate arer support from family, friends, or health and soial servies? Does the patient smoke? Is there evidene of drug or alohol misuse that may make the patient suseptible to infetion? Objetive examination Vital signs The vital signs that should be reorded in a patient with shortness of breath are listed in box 6. Box 6 Vital signs for assessing shortness of breath Respiratory rate and effort SpO 2 Peak expiratory flow rate (PEFR) (fig 2) Pulse rate Blood pressure Orientation and Glasgow oma sore Temperature Soial ontext In addition to the linial assessment, it is important to onsider the patient s ability to are for themselves or whether suitable support mehanisms are available. If these are absent, an they be arranged? Can the patient perform Figure 2 Peak flow meter in use. the normal ativities of daily living feeding and washing themselves and using the toilet either with or without support? The time of day and day of the week may also influene the deision about whether to admit or refer the patient, as this may ditate how quikly a patient ould be seen by their own GP or reviewed by the emergeny are pratitioner. General examination Look for signs of the unwell patient (see artile two in the series). A detailed examination of the respiratory system is mandatory for patients with shortness of breath. Remember, however, that myoardial infartion, aute oronary syndromes, and ongestive ardia failure an also result in respiratory distress, as may endorine and neurologial problems (for example Kussmaul s and Cheyne-Stokes respiration in hyperglyaemia and raised intraranial pressure respetively). If a respiratory problem annot be readily identified as the ause of the patient s symptoms, undertake an examination of the other systems. Elderly patients are likely to have multiple pathologies, so undertake a general systems examination Alhough shortness of breath an result from problems in many systems a useful lue is to note if there is any inrease in effort of breathing. This invariably means the problem has a respiratory basis. www.emjonline.om

344 For details of the respiratory examination, refer to boxes 3, 5, 6, and 7 of this artile and artile 2 of this series. Note if the patient has exessive prodution of sputum. What olour is this? Yellow, green, or brown sputum indiates a hest infetion. White frothy sputum, whih may also be tinged with pink, suggests pulmonary oedema. Look at the patient to determine their olour, and for signs of raised jugular venous pressure. Is the patient breathing through pursed lips, or using aessory musles, perhaps suggesting COPD? Are there signs of CO 2 retention (tremor of the hands, faial flushing, falling onsious level)? Palpate the trahea to hek that it is in the midline. Examine the hest and observe hest expansion. Is this the same on both sides? Is there evidene of hyperinflation? Are sars present from surgery? Is there evidene of hest wall deformity? Feel the hest to onfirm equality of movement, and hek for hest wall repitus and surgial emphysema. Is there evidene of hest wall tenderness or pain? Is any pain positional, or worsened on inspiration (as, for example, in pleurisy)? Feel for tatile voal fremitus (see the journal web site http://www.emjonline.om/supplemental). Listen to the hest. Peruss the anterior and posterior hest wall bilaterally at the top, middle, and bottom of the bak. Is the perussion note normal, dull, or hyper-resonant? Ausultate the hest at the same loations and in the axillae while the patient breaths in and out of an open mouth. Listen for the sounds of bronhial breathing, wheeze, or rakles. Listen for voal resonane (see journal web site http:// www.emjonline/supplemental) and pleural rubs. If it is unertain if a perussion note is dull or normal, ompare with the result of perussing over the liver (lower ribs on the right). The perussion note will sound dull as the liver is a solid organ. Tatile voal fremitus and voal resonane are inreased in onsolidation and dereased in pleural effusion and pneumothorax. If the adult patient omplains of symptoms of a respiratory trat infetion, undertake an ENT examination. Look in the mouth to examine for tonsullar and pharyngeal inflammation, and feel for enlargement of the lymph nodes in the nek. Do not attempt to examine the upper airway of a hild with respiratory distress assoiated with stridor or drooling. These findings may be indiative of epiglottitis and attempts to examine the mouth and throat may provoke omplete airway obstrution. In all patients with sudden onset of shortness of breath and in the absene of other findings strongly suggestive of a respiratory problem, undertake an examination of the ardiovasular system (see artiles two and three of this series). The pertinent features of the respiratory examination are summarised in box 7. Box 7 Pertinent features of the respiratory examination General Disoloured sputum Consider examination of ardiovasular, ENT, and other systems Feel (palpate) Chest wall tenderness Tatile voal fremitus Perussion note Crepitus Surgial emphysema Look (inspet) Skin olour Jugular venous pressure Traheal deviation Breathing through pursed lips Use of aessory musles Hand tremor Symmetry of hest wall movement Hyperinflation or fixed expansion Sars from previous surgery Chest wall deformity Listen (ausultate) Bronhial breathing, wheeze, or rakles Voal resonane Pleural rub ANALYSIS (DIFFERENTIAL DIAGNOSIS) Diagnosis is often straightforward with a typial history and findings. For example, the patient presenting with wheeze and tahypnoea may state that they have asthma. The skill is in determining the severity of the ondition. Few patients die as a result of the misdiagnosis of asthma but signifiant numbers die beause professionals or patients underestimate the severity of an episode. Differential diagnosis an also be very diffiult, the lassi situation being in distinguishing between an exaerbation of COPD and ardiogeni pulmonary oedema. This may be made simpler by the use of b-natureti peptide (BNP) estimations. This has reently been made available as a near-patient test and may beome inreasingly ommon in the out of hospital setting. Asthma Table 1 summarises the pointers in history and examination in patients with asthma that help to gauge the severity of an episode. Patients with severe or life threatening asthma need alm reassurane (even if the healthare provider is paniking internally), early treatment with b 2 agonists, oxygen, and immediate transfer to hospital. Patients with mild or moderate episodes who respond well to treatment may be suitable for home management with further inhaled b 2 agonists, oral ortiosteroids, and early review (tables 1 and 2). 2 COPD Exaerbations of COPD are ommon. These an be triggered by a number of fators but a viral infetion is the most frequent. Diagnosis is often simple but it is the assessment of www.emjonline.om

Table 1 Differential diagnosis of asthma Subjetive assessment Objetive examination History of: General findings inlude wheeze and Episodi wheezing inreasing dyspnoea Noturnal ough Moderate aute asthma: Previous diagnosis PEFR.50% normal (table 2) Previous episodes requiring intervention additional to Normal speeh maintenane drug therapy Respirations,25 Inreasing dyspnoea and wheeze Pulse,110 Dereasing wheeze in the absene of reovery Severe aute asthma: is a serious finding suggesting grossly inadequate ventilation PEFR 33 50% of normal (table 2) Preipitating fator, inluding infetion, exerise, exposure to Cannot omplete sentenes allergen, exposure to old air Respirations>25 Other atopy (for example, ezema, hay fever) Pulse>110 History of previous hospital admission (partiularly ICU)/need for Life threatening aute asthma: ventilation is ause for signifiant onern, suggesting brittle asthma PEFR,33% of normal (table 2) Asthma mediations may be evident SpO 2,92% on air/,95% on oxygen (inhalers with b 2 agonists and ortiosteroids are usual in adults; Silent hest (no wheeze) nebulisers and oral ortiosteroids suggest more signifiant problems) Cyanosis Patient or other household residents may smoke Feeble respiratory effort Possible limitations in ativities of daily living Bradyardia or arrhythmia Hypotension Exhaustion, hanged mental status, or falling GCS 345 Table 2 Personal best PEFR values with ranges for estimating severity of aute asthma episode If patient s personal best peak flow meter reading is: Normal variation above: Moderate aute asthma Severe aute asthma Life threatening aute asthma less than: 100 80 50 to 80 33 to 50 33 125 100 63 to 100 41 to 63 41 150 120 75 to 120 50 to 75 50 175 140 88 to 140 58 to 88 58 200 160 100 to 160 66 to 100 66 225 180 113 to 180 74 to 113 74 250 200 125 to 200 83 to 125 83 275 220 138 to 220 91 to 138 91 300 240 150 to 240 99 to 150 99 325 260 163 to 260 107 to 163 107 350 280 175 to 280 116 to 175 116 375 300 188 to 300 124 to 188 124 400 320 200 to 320 132 to 200 132 425 340 213 to 340 140 to 213 140 450 360 225 to 360 149 to 225 149 475 380 238 to 380 157 to 238 157 500 400 250 to 400 165 to 250 165 525 420 263 to 420 173 to 263 173 550 440 275 to 440 182 to 275 182 575 460 288 to 460 190 to 288 190 600 480 300 to 480 198 to 300 198 Table 3 Differential diagnosis of hroni obstrutive pulmonary disease (COPD) Subjetive assessment Objetive examination History of: Hyper-inflated hest Previous diagnosis with reent exaerbation Inreased end tidal CO 2, dereased SpO 2 and Inreasing wheeze and hest tightness yanosis (bronhitis and late stage emphysema) Inreased sputum prodution and purulene Normal end tidal CO 2 and SpO 2 and pink olour New peripheral oedema (emphysema) Episodi deterioration in ondition, possibly with Inreasing dyspnoea on exertion hospital admission Use of aessory musles of respiration Smoking (ommon) Possible produtive ough Family history Crepitations or wheezes may be present Reduing mobility Cor pulmonale (right heart failure, for example, Inreasing limitations in ativities of daily living ankle swelling) is a sign of late stage COPD Oupational exposure to dusts, et Inreasing pulse and respiratory rates indiate an Asthma may also be present exaerbation of COPD Mediations suh as b 2 agonists (inhaler or nebuliser), ortiosteroids, and antibiotis may be evident Chroni bronhitis is defined as a produtive ough on most days for 3 months of the year for >2 years COPD inludes hroni bronhitis (inreased airway resistane attributable to narrowing of the airways) and emphysema (dereased outflow pressure attributable to loss of elastiity in lung tissues) www.emjonline.om

Table 4 Differential diagnosis of aute pulmonary oedema (left ventriular failure/lvf) Subjetive assessment Objetive examination 346 History of: Pre-existing heart disease (undiagnosed hest pain, angina, myoardial infartion, aorti or mitral valve disease, tahyarhythmias) Inreasing dyspnoea Inreasing exerise intolerane Rheumati fever Lak of ompliane to presribed mediations Failure to ope with normal ativities of daily living Evidene of a wide range of drugs used to treat ardia onditions may be found, inluding b blokers, alium hannel blokers, ACE inhibitors, nitrates, aspirin, diuretis and anti-arrhythmis Severe dyspnoea inreased by reumbent positioning. May be worse at night. Cough produing white frothy sputum, sometimes tinged pink (this may be opious = frank pulmonary oedema) Crakles over affeted area Raised JVP Third heart sound (requires pratie to differentiate!) Mitral murmur (requires pratie to differentiate!) Possible arrhythmias Hypotension Chest pain may be present Dependent pitting oedema (generalised heart failure) Table 5 Differential diagnosis of shortness of breath with fever and malaise (pneumonia) Subjetive assessment Objetive examination History of: Inreasing dyspnoea Predisposing fators, suh as influenza, smoking, Dry ough beoming produtive (green purulent sputum) suppressed ough reflex (for example, oma), Fever pulmonary oedema, COPD, aloholism, Pleuriti hest pain (worse on inspiration, possibly immunosuppression, long term administration of positional, may be severe) broad range antibiotis, general debility or Consolidation: immobility Redued hest wall expansion on side of onsolidation Contat with person with pneumonia or reent Dull to perussion over affeted area hospital admission (less than two weeks previously) Inreased TVF and voal resonane over affeted area Inreasing breathlessness Crakles over affeted area Upper/lower respiratory trat infetion Wheeze General malaise Pleuriti rub There may be evidene of failure to ope with normal ativities of daily living the severity of the ondition that needs skill. The main differential diagnosis is of ardiogeni pulmonary oedema (LVF). A pneumothorax is an unommon reason for a severe sudden exaerbation of COPD. Knowledge of the patient s normal pulmonary funtion is important. Some patients with COPD have a normal PO 2 that would indiate severe respiratory failure in a normal person. Signs of exhaustion, inability to expetorate, or CO 2 retention are the main worrying features indiating a severe episode. Oxygen treatment in these patients should be titrated against the SPO 2 (ontrolled oxygen therapy see the North- West Oxygen Group guidelines). 1 If the episode is not severe and the patient has adequate home support, then hospital admission may be avoided (table 3). 3 Aute ardiogeni pulmonary oedema The onset is often sudden and severe. The patient is older and usually has a history of ishaemi heart disease although this may be the first indiation of heart problems. Aute MI is often a preipitating fator. Severe shortness of breath, white frothy sputum, tahypnoea, and tahyardia are ommon. Suh patients need to be transported to hospital, sitting upright if possible. Immediate treatment onsists of bual nitrates (providing the blood pressure is not low), oxygen, and intravenous opioids (table 4). Pneumonia Fever, malaise, and purulent sputum suggest a diagnosis of pneumonia. The riteria for home treatment varies from ountry to ountry (table 5). 4 CONDITIONS FOR EXCLUSION IF HOSPITAL ATTENDANCE IS NOT CONSIDERED APPROPRIATE Box 5 lists the key findings that indiate the need for immediate hospital admission in primary survey negative patients. Table 6 desribes additional findings determined from the seondary survey that will suggest the need for hospital admission. In asthma or COPD, failure to respond to the initial dose of a b 2 agonist (for example, nebulised salbutamol) is also an indiation for onsidering hospitalisation, as is a history of a previous near fatal attak regardless of the severity of the urrent episode. All patients with a first episode of pulmonary oedema or an aute exaerbation of a hroni problem should be admitted to hospital for further investigation and treatment. Pneumothorax Spontaneous pneumothorax is most ommon in tall, thin, fit young men (see table 6). It is an unommon ompliation of asthma and COPD. There are some rarer auses but these will be very unommon in the ommunity setting. If a pneumothorax is suspeted, the patient will need to be referred to hospital for a radiograph and further evaluation. Pulmonary embolism Half of all patients suffering for pulmonary embolism will develop this ondition while in hospital or long term are. The remainder will have an unknown aetiology or will have been exposed to a known risk fator (see table 6). If a pulmonary embolism is suspeted the patient will require www.emjonline.om

Table 6 Condition Findings from seondary survey suggesting need for hospital admission Key findings Pleural effusion Pneumothorax (most spontaneous pneumothoraies our in tall, thin, fit young adults and are ideopathi) Lung ollapse (bronhial obstrution) Pulmonary embolism (PE) History of aner, ardia failure, or renal failure Limited hest expansion on the affeted side Dull perussion note over the affeted area Redued breath sounds, TVF, and voal resonane over the affeted area Possible rakles in the presene of LVF Possible pleuriti rub (infetion) Traheal shift away from the effusion (late sign) Sudden onset of dyspnoea and pleuriti hest pain (early sign) Development of tension pnuemothorax may be identified by inreasing dyspnoea, and: Redued hest expansion on the affeted side Hyper-inflated, fixed hest wall on the affeted side Surgial emphysema (rare) Trahea deviated away from affeted side Chest hyper-resonant to perussion Dereased or absent breath sounds on the affeted side Raised JVP Deteriorating ardiovasular status (late sign) Dyspnoea Redued hest expansion on affeted side Traheal deviation towards side of ollapse Dull to perussion over non-inflated area Dereased TVF over affeted area Breath sounds absent or dereased over affeted area; inreased bronhial breathing elsewhere A Clinial features ompatible with PE Dyspnoea and/or Tahypnoea (.20 breaths per minute) and Heamoptysis and/or Pleuriti hest pain B Major risk fators for PE Major abdominal or pelvi surgery Hip or knee replaement Postoperative intensive are Late pregnany Caesarean setion Pueperium Lower limb frature Variose veins Abdominal, pelvi, or metastati malignany Redued mobility due to hospitalisation or institutional are Previous history of venous thromboembolism C The absene of another reasonable linial explanation for the signs and symptoms If A, B, and C are all onfirmed the likelihood of PE is high; If A and B or C are present the likelihood of PE is intermediate; If A is present but B and C are both absent the likelihood of PE is low, espeially in ases of pleuriti hest pain or haemoptysis not aompanied by breathlessness 347 Table 7 Treatment of asthma 2 Moderate aute asthma Severe aute asthma (or no response to treatment in moderate asthma) Life threatening aute asthma Protet and maintain airway as neessary Position for omfort (usually sitting upright) Salbutamol 5 mg via oxygen driven nebuliser If PEFR.50 75% of normal, give prednisolone 40 50 mg orally Treat and leave if patient responds to treatment Arrange re-assessment, possibly by telephone, at a suitable time Consider referring to GP or speialist nurse for delayed follow up if patient requires further support or review of treatment Oxygen via non-rebreathing mask* Repeat salbutamol 5 mg nebuliser at 5 to 15 min intervals until symptoms are ontrolled* Administer prednisolone 40 50 mg orally or hydroortisone 100 mg IV Consider treat and leave if patient fully responds to treatment and has adequate arer support If disharged, arrange re-assessment, possibly by telephone, at a suitable time Refer to GP for immediate appointment Oxygen via non-rebreathing mask* Start transportation to hospital Repeat salbutamol 5 mg nebuliser at 5 to 15 min intervals until symptoms are ontrolled* Administer prednisolone 40 50 mg orally or hydroortisone 200 mg IV* Oxygen via non-rebreathing mask* Repeat salbutamol 5 mg nebuliser at 5 15 min intervals until symptoms are ontrolled* Ipratropium 0.5 mg via nebuliser (may be mixed with salbutamol) Consider intravenous rystalloids in the presene of dehydration www.emjonline.om

348 urgent transfer to hospital for possible heparinisation or thrombolysis. 5 TREATMENT AND DISPOSAL (PLAN) The initial out of hospital treatment of eah of the four key onditions is given in table 7 and boxes 8 to 10. Interventions reommended in the JRCALC guidelines for paramedi use are asterisked. 6 Tension pneumothorax is a rare ompliation of asthma. Monitor for its signs and perform needle thoraoentesis (deompression) if these are present Chek the inhaler tehnique of patients left at home. 7 Tension pneumothorax is a rare ompliation of COPD. Monitor for its signs and perform needle thoraoentesis (deompression) if these are present Rule out aute MI: if present onsider opioids, nitrates, aspirin, heparin, and thrombolysis aording to relevant guidelines DISPOSITION FLOW CHART Figure 3 desribes the deision making proess for patient disposition. FOLLOW UP Patients with an aute exaerbation of the onditions disussed in this paper but not requiring hospital admission should be advised to request further assistane if their ondition deteriorates one the arer has left. Reassessment of the need for hospital admission is then mandatory. All patients provided with home are should be referred for an appointment with their general pratitioner within a suitable time frame for further assessment. This will inlude onsideration of the patient s ongoing ondition, their ability to use inhalers orretly, measurement of their respiratory funtion (FEV 1 ), and lifestyle management advie (for example, smoking essation, weight ontrol, exerise). ACKNOWLEDGEMENTS Thanks to Jim Wardrope, Peter Drisoll, and Colville Laird whose feedbak resulted in valuable improvements to earlier drafts of this paper. Contributions Malolm Woollard wrote the first draft of the paper. Malolm Woollard and Ian Greaves edited all subsequent drafts. Box 8 Treatment of COPD 3 Protet and maintain airway as neessary* Position for omfort (usually sitting upright)* Salbutamol 5 mg via nebuliser* Ipratropium 0.5 mg via nebuliser (may be mixed with salbutamol) Re-assess: if patient s ondition returns to their normal state, onsider managing at home: Confirm appropriate tehnique when using inhalers Consider inreasing dose of bronhodilator Consider oral ortiosteroids if: Previous reorded response to ortiosteroid therapy Dyspnoea is inreasing despite prior inrease in bronhodilator dose Consider antibiotis if two or more of the following are present: Inreasing dyspnoea Inreasing sputum volume Development of purulent sputum Refer to GP for appointment for re-assessment within 24 hours, If no response to initial nebuliser, transport to hospital. On route: Repeat salbutamol 5 mg nebuliser at 5 min intervals until symptoms are ontrolled* Administer oxygen at 24 to 28% via Venturi mask initially Monitor SpO 2 and adjust oxygen onentration to maintain at usual level for patient or at 90 to 92% if unknown (see North West Oxygen Group guidelines) Consider supporting ventilation if SpO 2 annot be maintained, patient beomes exhausted or respiratory rate or effort delines inappropriate Box 9 Treatment of aute pulmonary oedema Allpatientswithanauteexaerbationof pulmonary oedema require hospitalisation Protet and maintain airway as neessary* Position for omfort (usually sitting upright)* Oxygen via non-rebreathing mask* Use ontinuous positive airway pressure ventilation (CPAP) if available: otherwise onsider assisting ventilations with BVM if respiratory failure evident 400 mg glyeryl trinitrate spray if systoli BP.90 mm Hg* Consider reording 12 lead ECG Start transportation to hospital* Consider seond dose of GTN if SBP.90 mm Hg* Give furosemide 40 mg IV* Give morphine 5 20 mg IV (monitor respirations and assist ventilation if respiratory depression beomes evident) Consider repeating furosemide 40 mg IV at 10 minute intervals to a maximum dose of 120 mg* Consider salbutamol 5 mg via nebuliser in the presene of wheeze* Consider further GTN 400 mg if SBP.90 mm Hg Information on tatile voal fremitus and voal resonane is available on the journal web site (http:// www.emjonline.om/supplemental). www.emjonline.om

Primary survey positive? Figure 3 Disposition flow hart (shortness of breath). 349 Exlude: Stridor assoiated with other key findings Use of aessory musles Need to sit upright Traheal tug Inter-ostal reession Expiratory wheeze assoiated with other key findings Cessation of expiratory wheeze without improvement in ondition Inability to speak in whole sentenes Respiratory rate < 10 or > 29 Weak respiratory effort Dereased, asymmetrial, or absent breath sounds Oxygen saturation < 92% on air or < 95% on high onentration oxygen PEFR < 33% of normal Hyperapnia (measured with end tidal CO 2 monitor) Tahyardia (> 120) or bradyardia (late and ominous finding) Arrhythmias Pallor and/or yanosis (partiularly entral yanosis) Cool lammy skin Falling blood pressure (late and ominous finding) Changed mental status onfusion, feeling of impending doom, ombativeness Falling level of onsiousness Exhaustion (+/ musular hest pain) Yes Hospitalise urgently No Primary survey negative patient requiring hospital admission? After initial treatment, exlude: Inspiratory or expiratory noises (stridor or wheeze) audible without the aid of a stethosope Cannot speak whole sentenes Respiration > 25 breaths per minute Pulse > 100 beats per minute Supplemental oxygen required to maintain SpO 2 at 95% above (or at 'usual' level of SpO 2 for COPD patients) PEFR < 50% of normal Inability to rule out MI or aute oronary syndrome Lak of arer support for those patients unable to look after themselves Yes Hospitalise immediately No Evidene from seondary survey of need for admission? Hospitalise No During seondary survey, exlude: Pneumothorax Pleural effusion Lung ollapse Previous history of near fatal episode (asthma and COPD) Aute pulmonary oedema Pulmonary embolism No response to treatment Yes Consider treat and disharge Refer to GP for follow up assessment www.emjonline.om

350 Box 10 Treatment of pneumonia 4 If no evidene of respiratory failure or severe respiratory distress, and the patient has adequate arer support and an manage normal daily ativities of living (see hest pain artile): Position for omfort (usually sitting upright) Antibioti therapy Refer to GP for appointment for follow up within 24 hours In the absene of adequate arer support and if unable to manage daily tasks of living, or if tahyardia, tahypnoea or hest pain are present: Consider hospital admission Oxygen via non-rebreathing mask if required to maintain SpO 2 above 95% Consider intravenous rystalloids in the presene of dehydration... Authors affiliations M Woollard, I Greaves, Pre-hospital Care Researh Unit, Department of Aademi Emergeny Mediine, The James Cook University Hospital, Middlesbrough, UK Further reading Marsh J. Respiratory examination. In: Crash ourse. History and examination. London: Mosby International, 1999. MGill University. Examples of normal and abnormal breath sounds an be found at the MGill University virtual stethosope web pages. http://www.musi.mgill.a/ausultation/ the_lungs.html (aessed 29 Jan 2004). O Conner DJ, Jones BG. Pathology of the respiratory system. In: Crash ourse. Pathology. 2nd edn. London: Mosby International, 2002. British Thorai Soiety. The British Thorai Soiety web site ontains extensive information about respiratory illness and relevant guidelines. http://www.brit-thorai.org.uk (aessed 29 Jan 2004). Wardle T. Respiratory emergenies. In: Greaves I, Porter K, eds. Pre-hospital mediine. The priniples and pratie of immediate are. London: Arnold, 1999. REFERENCES 1 Murphy R, Makway-Jones K, Sammy I, et al. Emergeny oxygen therapy for the breathless patient. Guidelines prepared by North West Oxygen Group. J Aid Emerg Med 2001;18:42 3. 2 British Thorai Soiety. The BTS/SIGN British guideline on the management of asthma. Thorax 2003;58(suppl 1):i1 94. 3 The British Thorai Soiety Standards of Care Committee. Guidelines on the management of COPD. Thorax 1997;52(suppl 5):S1 28. 4 British Thorai Soiety. The British Thorai Soiety. Guidelines for the management of ommunity aquired pneumonia in adults. Thorax 2001;56(suppl 4):iv1 64. 5 The British Thorai Soiety Standards of Care Committee Pulmonary Embolism Guideline Development Group. BTS Guidelines for the management of suspeted aute pulmonary embolism, 2003. Thorax 2003;58:470 84. 6 Joint Royal Colleges Ambulane Liaison Committee. Pre-hospital guidelines version 2.1. London: JRCALC/Ambulane Servie Assoiation, 2002. 7 Asthma Organisation. National asthma ampaign. How to use your inhaler. http://www.asthma.org.uk (aessed 29 Jan 2004). www.emjonline.om