Managing the Dyspnoeic Patient in A&E: A Guide for Junior Doctors

Introduction

As a junior doctor in the Accident and Emergency (A&E) department, encountering patients with dyspnoea (shortness of breath) is common. Dyspnoea can be a symptom of various underlying conditions, some of which are life-threatening and require prompt recognition and treatment. This guide will help you navigate the approach to a dyspnoeic patient, focusing on history taking, examination, investigation, and management.

History Taking

Key Questions to Ask

1. Onset and Duration

   • When did the shortness of breath start?

   • Was the onset sudden or gradual?

2. Severity and Progression

   • How severe is the dyspnoea on a scale of 1 to 10?

   • Has it been getting better, worse, or staying the same?

3. Associated Symptoms

   • Do you have chest pain? (Explore the nature, location, and radiation of the pain)

   • Any cough? (Ask about the presence of sputum, its color, and amount)

   • Do you have fever or chills?

   • Any wheezing or stridor?

   • Any recent weight loss, night sweats, or swelling of legs?

4. Exacerbating and Relieving Factors

   • What makes the dyspnoea worse? (e.g., exertion, lying flat)

   • What makes it better? (e.g., sitting up, resting)

5. Past Medical History

   • Do you have any history of heart disease, lung disease (e.g., asthma, COPD), or recent infections?

   • Any history of allergies or anaphylaxis?

   • Have you had any recent surgeries or trauma?

6. Medications

   • What medications are you currently taking? (including over-the-counter and herbal supplements)

   • Any recent changes in your medications?

7. Social History

   • Do you smoke? If so, how many cigarettes a day and for how many years?

   • Do you have any exposure to occupational or environmental hazards?

   • Do you use recreational drugs?

8. Family History

   • Is there a family history of heart or lung disease?

Examination

General Inspection

• Observe the patient’s overall appearance: Are they in distress, using accessory muscles to breathe, or cyanosed?

• Check their level of consciousness and ability to speak in full sentences.

Vital Signs

• Respiratory Rate: Note tachypnoea or bradypnoea.

• Oxygen Saturation: Use a pulse oximeter to check SpO2 levels.

• Heart Rate and Blood Pressure: Look for signs of shock or hypertension.

• Temperature: Check for fever.

Respiratory Examination

1. Inspection

   • Observe for chest wall deformities, asymmetry, or paradoxical movements.

   • Look for signs of infection such as a productive cough or hemoptysis.

2. Palpation

   • Assess for tracheal deviation.

   • Check for chest wall tenderness or subcutaneous emphysema.

3. Percussion

   • Percuss the chest to identify areas of dullness (suggestive of effusion) or hyperresonance (suggestive of pneumothorax).

4. Auscultation

   • Listen for breath sounds: Are they diminished or absent?

   • Note any added sounds such as wheezes, crackles, or stridor.

Cardiovascular Examination

• Check for signs of heart failure: Jugular venous distension, peripheral edema, and hepatomegaly.

• Listen for heart murmurs or gallops.

Investigations

Initial Bedside Tests

• Pulse Oximetry: Assess oxygen saturation.

• Arterial Blood Gas (ABG): Evaluate gas exchange and acid-base status.

• ECG: Identify cardiac causes such as myocardial infarction or arrhythmias.

• Peak Expiratory Flow Rate (PEFR): Useful in asthma exacerbations.

Laboratory Tests

• Full Blood Count (FBC): Look for infection or anemia.

• Urea and Electrolytes (U&E): Assess renal function and electrolyte imbalances.

• D-dimer: Consider in suspected pulmonary embolism.

• Cardiac Markers (Troponin): Evaluate for myocardial infarction.

• BNP/NT-proBNP: Assess for heart failure.

Imaging

• Chest X-ray: Evaluate for pneumonia, pneumothorax, pleural effusion, or heart failure.

• CT Pulmonary Angiography (CTPA): If pulmonary embolism is suspected.

• Echocardiography: Assess cardiac function and structural abnormalities.

• 
  

Management Plan

Immediate Management

1. Oxygen Therapy

   • Administer oxygen to maintain SpO2 > 94% (88-92% in COPD patients).

2. Ventilatory Support

   • Consider non-invasive ventilation (NIV) or intubation for severe respiratory distress or failure.

3. Pharmacological Treatment

   • Bronchodilators: For asthma or COPD exacerbations.

   • Steroids: Inflammatory or allergic causes.

   • Antibiotics: If bacterial infection is suspected.

   • Diuretics: For heart failure with pulmonary edema.

   • Anticoagulation: For suspected or confirmed pulmonary embolism.

   • Analgesics and Sedatives: For pain and anxiety, ensuring not to depress respiration further.

Specific Treatments

• Asthma/COPD: Nebulized bronchodilators, corticosteroids, magnesium sulfate.

• Heart Failure: Diuretics, nitrates, and inotropes if needed.

• Pulmonary Embolism: Anticoagulation or thrombolysis in severe cases.

• Pneumonia: Empiric antibiotics tailored to the clinical scenario.

• Pneumothorax: Needle decompression for tension pneumothorax, chest drain for others.

Monitoring and Reassessment

• Continuous monitoring of vital signs and oxygen saturation.

• Regular reassessment of respiratory status and clinical response to treatment.

• Escalate care if the patient deteriorates or fails to improve.

Approaching a dyspnoeic patient in A&E requires a systematic and thorough approach. By carefully taking a history, conducting a detailed examination, performing appropriate investigations, and initiating timely management, you can effectively address the underlying cause and improve patient outcomes. Always remain vigilant for signs of deterioration and be prepared to escalate care as necessary.