Management of acute shortness of breath
Primary topic:
Initial management of patient with acute exacerbation of COPD
Secondary topics:
Management of acute COPD according to local protocols
Decision making regarding non-invasive ventilation
(Management of patients on NIV)
(Management of pneumothorax)
Curriculum mapping
Foundation programme 7.1 (Core skills in relation to acute illness)
Knowledge
Common presenting symptoms and signs of acute illness
Causes of shortness of breath
Causes of confusion
Clinical interpretation of acutely abnormal physiology
How comorbidity affects decision making in acute illness
Common derangements of blood gases
Safe oxygen therapy
Safe use of analgesia
Competencies
Promptly assesses the acutely ill or collapsed patient
Responds appropriately to abnormal physiology
Reassesses appropriately
Foundation programme 7.2 (Resuscitation)
Knowledge
Contents of advanced life support
Competencies
Able to initiate resuscitation at advanced life support level
Foundation programme 7.3 (Management of the “take”)
Knowledge
Indications for urgent investigations and therapy
When to seek help and from whom
Competencies
Able to prioritise
Interacts effectively with other health care professionals
Keeps patients and relatives informed
Receives and makes referrals appropriately
Delegates effectively and safely
Performs safe handover
Learning Objectives
At the end of this session the doctors should be able to:
In scenario role;
Confidently assess an acutely ill patient using the ABCDE approach
Recognise acute exacerbation of COPD
Take a focused history relating to potential differential diagnosis
Initiate appropriate initial management
Apply COPD protocol
Reassess after intervention
Appropriately handover to a colleague
In observation role;
Critique colleague performance
In debrief;
Discuss different approaches to the clinical problem
Discussion topics
Infective causes of exacerbations of COPD
Initial oxygen therapy in this patient
Consideration of which patients should be considered for NIV
Decision making regarding ceiling of treatment
Reassessment of patients on NIV
Recognition and management of acute pneumothorax
Scenario
A 74 year old male retired electrician presents to the ED with shortness of breath. He has a background history of COPD with 2 admissions in the last 18 months with no HDU / ITU admissions, no home oxygen and no home nebulisers.
His other past medical history includes NIDDM and a CVA 5 years ago with full recovery. He lives with his wife and is independent. They have returned from a holiday to Spain 10 days ago.
He presents with a 1 week history of cough with green sputum and is feeling feverish.
|
STAGE |
EVENTS |
OBSERVATIONS / AVAILABLE RESULTS |
EXPECTED ACTIONS |
PROMPTS |
|
Initial assessment
|
F1 arrives to see the patient in a very busy department. A nurse has applied monitoring and 15L oxygen.
Patient is feeling short of breath. Unable to talk in full sentences. Mildly confused. |
Sats: 93% on 15L 02 Pulse: 100 BP: 150/90 RR: 32 Temp: 38
|
Introduces self Explains throughout to patient Takes focused but adequate history. Recognises confusion.
Airway: Assesses airway as patent
Breathing: Assesses respiratory rate and SaO2 Palpates, percusses and auscultates noting bilateral creps/ diffuse mild wheeze. Notes oxygen too high and reduces (or switches off for gas in air with plan to recommence). Checks for C02 narcosis Sits up ABG
Circulation: Notes observations. Asks for cap refill time. Requests ECG. Inserts cannula and takes bloods |
Encourage to talk to patient and treat as would usually, if doesn’t take much history.
If does not turn down 15L oxygen patient gets significantly more confused over time.
If forgets bloods or ECG, nurse to ask “anything else?” but no other prompt – let scenario run. |
|
Initial management |
Patient is still complaining of breathlessness but is less confused if oxygen reduced. Unable to talk in full sentences.
Patient is managed according to initial part of COPD protocol |
Sats 88% on air/2L or 93% on 15L Pulse 104 BP 130/85 RR 32 Temp 38
ECG shows sinus tachycardia
ABG on high flow 02 P02 – 10.5 PC02 – 8.8 HC03 – 32 BE - -5 pH – 7.31 Hb 11 Lactate 1.2
ABG on air or 2L 02 P02 – 7.6 pC02 – 8.0 HC03 – 32 BE - -2 pH – 7.31 Hb 11 Lactate 1.2
CXR shows diffuse bronchopneumonia
|
Recognises that at risk of retaining C02 and turns down 02
Requests portable CXR.
Recognises infective exacerbation of COPD.
Chooses appropriate antibiotics and follows protocol. (Amoxicillin, IV hydrocortisone 200mg, nebulised salbultamol and atrovent
|
If still does not recognize high flow 02, nurse to handover to colleague stating “on high flow oxygen” – if still no reduction, new nurse to check – “is high flow OK?”
Oxygen therapy should be justified – 28% to 40% acceptable as long as plan to monitor sats and recheck ABG. 02 sats can change accordingly. |
|
Reassessment |
Patient still short of breath despite treatment. Getting tired.
F2 could arrive at this point. |
BP 130/86 P 110 Sa02 90 – 91 % on 2 - 5L 02 RR 30 Temp 37.9
|
Recognises tiring. Assesses ABCDE
Airway – assesses as patent
Breathing – as previous. Using accessory muscles.
Circulation – as previous
Calls for help.
|
Nurse can prompt “He looks very tired doctor”.
|
|
Management after reassessment |
Patient still very short of breath despite treatment. |
BP 130/86 P 110 Sa02 90 – 91% on 2 – 5L 02 RR 30 Temp 37.9
|
Maximises medical therapy (iv salbutamol, magnesium)
Gives clear update of situation to seniors.
Assesses patient for potential NIV and discusses this with seniors. |
Nurse can prompt “Are there any other options, doctor?”
If does nothing appropriate eventually patient has a cardiorespiratory arrest. |
|
Further reassessment (If doctors progressing very well) |
Patient commenced on NIV and becomes increasingly agitated, trying to sit up further and take mask off. Appears increasingly breathless. |
BP 90/50 P 130 Sa02 84% on 4L via NIV RR38 T 37.8 |
Recognises deterioration and conducts re-examination
Airway – assesses patent
Breathing: Assesses respiratory rate and SaO2 Palpates, percusses and auscultates noting reduced air entry on right side, hyper-resonance and tracheal deviation.
Circulation: Notes evidence of circulatory shock
Makes diagnosis of right tension pneumothorax |
Nurse can prompt to reassess “He isn’t looking very well doctor, what do you think is happening?” etc |
|
Management of deterioration |
Patient commenced on NIV and becomes increasingly agitated, trying to sit up further and take mask off. Appears increasingly breathless. |
BP 90/50 P 130 Sa02 84% on 2L via NIV RR38 T 37.8 |
Calls for help and stops NIV. Calls for resus trolley.
Performs needle thoracocentesis on right site, identifying landmarks correctly.
Explains need to perform chest drain on right side |
If takes ABG, orders CXR or does nothing eventually patient deteriorates futher and has a cardiorespiratory arrest. |