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)


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


Promptly assesses the acutely ill or collapsed patient
Responds appropriately to abnormal physiology
Reassesses appropriately


Foundation programme 7.2 (Resuscitation)


Contents of advanced life support


Able to initiate resuscitation at advanced life support level


Foundation programme 7.3 (Management of the “take”)


Indications for urgent investigations and therapy
When to seek help and from whom


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


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.






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



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.


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


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


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.