Approach to

breathlessness in ETD
 Dyspnoea

Subjective feeling of difficulty in breathing

Tachypneic = RR> normal
Spo2 = <95%

Hyperventilation
Sensation of dyspnea associated with excessive breathing
(Tidal volume x RR) > demands ; pH =
 CAUSES

CARDIAC RESPIRATORY OTHERS

Acute pulmonary Acute exacerbation Metabolic acidosis :
oedema bronchial asthma DKA, Uremia
Heart failure Chronic obstructive Adult respiratory distress
pulmonary disease syndrome
Cardiac tamponade Pneumonia Anaphylaxis
Acute coronary Pulmonary embolism Anemia
syndrome
Pericarditis Pneumothorax Diaphragmatic splinting
Aortic dissection Pleural effusion Hyperventilation
syndrome
Cardiac dysrhythmias Lung collapse
 Triage

AGE respiration for neonates/ child/ adult

Normal RESPIRATION RATE
Birth upto 1 month 40-60/min
1 month upto 1 year 26-40/min
1-2 years 20-30/min
2-6years 20-30/min
Adolescent 16-24/min
Adult 15-20/min
 Clinical Assessment

Associated symptoms : cough, chest pain, fever, lower limb swelling

Past medical History : Asthma, Congestive cardiac failure
Recent trauma
Exacerbating factors : exposure to allergens
Relieving factors : MDI or Nebulizer
 Physical Examination

General appearance : cyanosis, confusion, drowsiness, tachypnea, pallor

Respiratory : lung crepitations, air entry good and equal
Cardiavascular : evidence of heart failure (raised JVP, pedal oedema,lung
crepitations)
Others : skin- urticarial
: severe dehydration in DKA
: trauma
 Bronchial Asthma

Chronic inflammatory disorder characterized by variable obstruction with

recurrent or chronic wheeze and/or cough.
Usually reversible but some patients with chronic asthma may lead to
irreversible conditions.
Management Of Acute Asthma In ETD

1) Initial PEF > 75% (Mild acute asthma)

In this situation, just given the patients usual inhaled bronchodilator (e.g. salbutamol,
terbutaline)
Observe for 60 minutes. If the patient is stable and PEF is still >75%, allow discharge.

Before discharge:
Asthma action plan
ensure patient has enough supply of medications
check inhaler technique and correct if faulty
advise patient to return immediately if asthma worsens.
make sure patient has a clinic follow-up appointment
2) Initial PEF < 75%
i) Immediate Treatment With :
a. High concentration oxygen
b. Nebuliser (VN or AVN) with oxygen supplementation.
c. Prednisolone tablets 30mg stat or IV Hydrocort 200mg stat.
ii) ABG
iii) Chest xray
iv) ECG
v) IV Antibiotics if theres infection
 Non-responders/partial response
- IV MgSO4 1amp (2.47gm) in 100cc slow bolus over 20minutes
- Aminophylline

- Prepare for rapid sequence intubation if symptoms still persist

 Chronic Obstructive Pulmonary
Disease

a preventable and treatable respiratory disorder largely caused by

smoking or other allergen exposure.
is characterised by progressive, partially reversible airflow obstruction and
lung hyperinflation with significant extrapulmonary (systemic) which may
contribute to the severity of the disease.
History of exposure : smoke, occupational dust, etc
 Pulmonary Embolism

is not an isolated disease of the chest but a complication of venous

thrombosis.
PE is preceded by DVT, the factors predisposing to the two conditions are
the same and broadly fit Virchows triad of venous stases injury to the
vein wall enhanced coagulability of the blood
ECG : T-wave inversion in anteroseptal and inferior leads (68%)
Minor PE : Sinus tachycardic
Massive PE : S1Q3T3
 Flow stasis Endothelial damage Coagulation abnormalities

Prolonged immobilization Local trauma Polycythemia

Trauma/surgery - 4weeks Surgery of legs and pelvis Platlet abnormalities

Congestive Heart Failure Vasculitis Malignant neoplasia

Obesity Burns Deficiency of anti-thrombin iii,

protein C and S

Spinal Cord Injury Electric Shock

Infection

History of thromboembolism
 Classification

Pulmonary History Vascular Presentation

embolism obstruction
Acute minor Short, sudden < 50% Dyspnoea with or
onset without pain and
haemoptysis
Acute massive Short, sudden > 50% Right heart strain
onset with or without
haemodynamic
instability
Subacute massive Several weeks > 50% Dyspnoea with
right heart strain
 Management

Monitor vital signs

Give oxygen or intubate if unable to maintain oxygenation
2 large bore IV lines
ABG reduced PaO2 & PaCO2 normal or reduced
Blood investigation FBC, electrolytes
Fluid resuscitatioins
ECG T wave inversion in anteroseptal and inferior leads (68%)
D-dimer ELISA 85-94%(sensitivity)
GXM
 Chest xray
Other investigations

Bedside cardiac echocardiography right ventricle can be dilated

CTPA computed tomographic pulmonary angiography

If suspected PE start IV Heparin 5000iu or S/C Fundaparinaux

Refer medical
 Reference

Guide to the essentials in Emergency medicine Shirley Ooi

Academy of Medicine of Malaysia CPG
Global Initiative for Asthma