ED training
Respiratory/
patient with dyspnea
Dr Jaycen Cruickshank
Emergency Medicine Training Hub
Ballarat & Grampians Region
2012
Respiratory - dyspnea
Learning objectives
The respiratory session will examine contrasting clinical cases of dyspnoea that will illustrate the
principles of diagnostic reasoning. lmportant physical findings that help discriminate different
causes of dyspnoea will be discussed along with appropriate initial investigations.
Learning objectives
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Be able to describe the differences and similarities in the medical history, physical examination
and investigations of common or life threatening causes of dyspnoea.
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To manage asthma and pneumonia using best practice guidelines
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To be able to use the Wells score & PERC rule in diagnosis of PE
Pre reading
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Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK
: John Wiley & Sons, 2011. Chapter 36 Shortness of breath. Chapter 7 Blood gas analysis.
Other learning resources
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Relevant clinical clinical guidelines at Ballarat Health Services:
Refer to ED lecture series and self directed
workbooks
Other learning resources
Other learning resources
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http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/
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Wells et al. Excluding pulmonary embolism at the bedside without diagnostic imaging:
management of patients with suspected pulmonary embolism presenting to the
emergency department by using a simple clinical model and d-dimer. Ann Intern Med.
2001 Jul 17;135(2):98-107. http://www.ncbi.nlm.nih.gov/pubmed/11453709
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Written asthma action plans. http://www.nationalasthma.org.au/managingasthma/controlling-your-asthma/written-asthma-action-plans
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Pneumonia severity scoring systems for community-acquired pneumonia in adults
(Appendix 2.4) http://jasper.tg.com.au/complete/tgc/abg/8052.htm
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http://lifeinthefastlane.com/2009/11/a-classic-respiratory-case/
Preparation slides
These may be pre reading +/- presented by teacher
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The first part of this presentation is designed
to be pre reading.
Learners are encouraged to do some reading
before the tutorial
The slides may be presented briefly at the
start of a session to recap
Your hospital should have some clinical
guidelines which will provide relevant local
information
How do we make a diagnosis
in a patient with dyspnea?
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History
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Cardinal features
Associated features
Risk factors (for diseases), past history (known
diseases), respiratory reserve “what can do
usually?”
Examination findings
Suitable/targeted investigations
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CXR, ECG, ABG’s, basic bloods
Lung function, CT, VQ, exercise test, echo
Emergency Department HMO education series
2012
A focussed history determines
both diagnosis and severity.
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SOB + associated symptoms
suggests a cause or differential
diagnosis
SOB + Pleuritic pain=
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SOB + wheeze =
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Inspiratory obstruction e.g croup
SOB + fever/cough/sputum =
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Asthma, COPD
SOB + stridor =
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Pneumonia, pneumothorax
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Pneumonia, other infection
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The severity of symptoms
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E.g is the person breathless at
rest, on exertion
Certain features aid diagnosis
Acute onset
Pneumothorax, PE, AF, APO, asthma
Gradual onset or with exertion
Cardiac cause, chronic anaemia
Worse at night, or lying down
Cardiac failure
SOB + haemoptysis
Upper airway cause, Pneumonia, PE,
cancer, vasculitis
Emergency Department HMO education series
2012
Background history
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Would you prefer to know risk factors for disease or known diseases?
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Ask about
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Exacerbations of known diseases are common and the diagnostic challenge is likely to focus on precipitant,
and the severity of the consequences of the exacerbation
Medications, including doses, compliance, recent changes
Who normally looks after the patient and where
Is there access to a good summary of recent treatment – think the GP, specialist clinic letters,
recent admissions
As you build up a differential diagnosis, ask questions that are relevant to each
differential
e,g I am thinking PE, so I will ask about recent travel, perhaps use the Well’s criteria
I am thinking pneumonia, I might ask about hospital vs community acquired,
immunosuppresion, contacts, birds, known recent outbreaks e.g Legionella
I am thinking what should I not miss, e.g cardiac causes
This type of approach to differential diagnoses is often helpful when working through
a list of possible diseases.
Paediatrics
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A quick reminder that for
paediatric assessment,
there are resources
available to assist with
normal values
Hypoxia needs immediate
correction, remember
cyanosis a pre terminal sign
in children
Most of the examination can
be completed without O2
sats or a stethoscope using
observation
Emergency Department HMO education series
2012
You need to be familiar with this for winter.
Standardised way to assess, present, refer kids.
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The Royal Children’s clinical guidelines are an
excellent resource to look up while working in the
Emergency Department.
http://www.uhs.nhs.uk/Media/suhtideal/TopNavigatio
nArticles/SkillsForPractice/ClinicalSkills/paediatricas
sessment.pdf
Recognition of the seriously ill child
http://paeds.org/apls/aplsrecog.html
the structured approach to the seriously ill child
http://www.paeds.org/apls/aplsapp.html
Emergency Department HMO education series
2012
Clinical cases to demonstrate
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We have a very thorough powerpoint
presentation that contains more detail, a very
methodical approach.
Highly recommended.
The rest of this presentation will contain
some cases.
A further series of cases will be presented at
the actual teaching session.
Case A
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A young man presents to the Emergency
Department via ambulance
He complains of sudden onset of SOB.
Present for a few hours and now quite
severe.
Emergency Department HMO education series
2012
Further history
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Previously well, smokes 10 cigarettes/day
Left sided chest pain
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Moderate
Pleuritic
Started with the SOB
Is there anything else you would like to ask?
What is your ddx?
Emergency Department HMO education series
2012
Differential diagnosis
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Pneumothorax
Arrhythmia
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Pulmonary Embolism
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Much less likely
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Not to be mentioned
before all organic
causes considered
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Asthma (less likely)
Pneumonia
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anxiety
Imagine that being your
diagnosis and you
missed the
pneumothorax…
Emergency Department HMO education series
2012
Examination findings
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Looks unwell, quite
distressed with  WOB
RR 26, HR 125 SR, BP
80/60, afebrile
Saturation 93% RA (room
air)
Trachea midline
 chest expansion on the
left
Hyperesonant percussion
note on the left
 air entry left lung
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What is going on?
Is this serious?
What is your immediate
management?
Emergency Department HMO education series
2012
Describe this CXR
… ideally this intervention before this CXR…
Emergency Department HMO education series
2012
Diagnosis and management?
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Initial therapy?
Who will help you?
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Where you are working,
will you call a MET, ask
for senior help?
Urgent chest tube (this
may have even been
done without a CXR if
the patient was unwell
enough)
Emergency Department HMO education series
2012
Describe this CXR
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See notes for report
Emergency Department HMO education series
2012
Describe this CXR
Emergency Department HMO education series
2012
Case B
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Young man
Brought to the ED by
his partner
Progressive SOB over
48 hours.
Now present at rest
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How is your differential
diagnosis altered by the
gradual onset?
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Asthma
Pneumonia
Other?
Emergency Department HMO education series
2012
Further history & examination
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Wheeze
Dry cough
Recent URTI
Childhood asthma (age
3-12), hay fever
No cardiac history
No risk factors for PE
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RR 24, HR 110 SR, BP
110/70
Sat 97% RA
Widespread wheeze
(what causes this
sound?)
Emergency Department HMO education series
2012
Investigations
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If the CXR is normal…
Peak Flow 300/min (how does this
help us?)
ABG ph 7.5/CO2 30/O2 70/HCO3
23
What do the blood gases show?
How severe is the problem
What if the CXR not normal, as
seen on right
Does it exclude asthma?
Emergency Department HMO education series
2012
Diagnosis is asthma:
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The treatment plan is easy, but can you
document it well?
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Bronchodilators, corticosteroids, oxygen
Describe the stickers used to standardise
prescribing in the ED at Ballarat Health
Services
Describe a safe asthma discharge plan
What are asthma action plans?
http://www.nationalasthma.org.au/health-professionals/tools-for-primary-care/asthma-action-plans/asthma-actionplan-library
Emergency Department HMO education series
2012
What scoring tools for
pneumonia?
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CURB-65, SMARTCOP?
How do scoring tools help predict:
 Need for admission, and appropriate ward
 Antibiotics and route
 Mortality
Is it acceptable to write clinical notes on a patient with a
diagnosis of pneumonia and not document severity using
one of these tools? No
Various website and apps can assist you in
remembering them. www.mdcalc.com
Emergency Department HMO education series
2012
Further cases…
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To be presented at the teaching session.
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See part 2 & 3