NHS Lambeth Clinical Commissioning Group
NHS Southwark Clinical Commissioning Group
Lambeth and Southwark Adult Breathlessness Assessment Algorithm
Common Causes of Breathlessness to Consider
Focus on co-morbidities
Cardiac
Respiratory
Mental Illness
/Addiction
Fitness/Lifestyle
Anaemia/Kidney
disease
Everyone who is breathless will have some degree of anxiety
If the patient already has a diagnosis causing breathlessness consider at each stable review (or if symptoms
worsening) whether this remains the only diagnosis and whether you need to reconsider causation.
STEP 1
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The history and examination still constitutes 90% of most diagnoses
HISTORY
Smoking history (pack years) and what is smoked including
tobacco, cannabis and other smoked drugs
Impact of breathlessness on daily life
Levels of habitual physical exercise
Environmental and occupational risk factors
Acute or Chronic breathlessness
Co-morbid conditions/Medications
Sleep Quality
Mental Health/Psychological Distress
Onset of breathlessness associated with identifiable emotional
/physical event
Consider professional carer support and informal systems
around the patient ie. relatives, neighbours etc
STEP 2
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EXAMINATION
Vital signs: BP, Pulse (rate and rhythm),
RR, Temperature, oxygen saturation
Observe breathing pattern (use of
accessory muscles)
Auscultate chest & assess airways patency
Assessment for peripheral oedema and
JVP
BMI, waist circumference, neck
circumference
PEF % predicted (for age, sex and height)
Expired carbon monoxide (ppm)
Identify Type of Breathlessness (Code breathlessness using READ code 173)
Acute severe breathlessness (less than 48 hours)
Consider admission (Red Flags: O2<92%, bradycardia
OR
Chronic persistent breathlessness (daily for more than 6 weeks)
Continue to follow breathlessness algorithm
<60bpm, tachycardia >100bpm, PEF<33% of best or
predicted, RR>30 breath/mn)
Provide patients with chronic persistent breathlessness leaflet ‘Taking Charge of your Breathlessness’
STEP 3
Tier 1 Investigations for presentation of chronic breathlessness
The minimum tests required for all patients presenting with chronic breathlessness:
Full Blood Count
Urea & Electrolytes
Initial
ECG (scan using "photo" setting)
Albumin/Creatinine Ratio
Consultation Thyroid Function Test
NT-ProBNP
PHQ4 (screening for anxiety PHQ2 and
Peak Flow Diary
depression GAD2) – Assess the extent to
which anxiety and/or depression are
contributing to the breathlessness, and/or
associated distress, and/or ability to selfmanage
From the tests results identify possible contributory factors to the breathlessness and confirm suspected
diagnoses through step 4 investigations
Subsequent
Consultation
Holistic
Assessment
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Liver Function Test
Microspirometry (FEV1)
Chest X-ray (if not done
within last 6 months)
Breathlessness Score –
MRC Scale
STEP 4
Tier 2 Investigations for presentation of chronic breathlessness
Based on history, examination and tier 1 investigations should further tests be carried out to confirm diagnoses or to
provide further information? Only order tests if you would act upon the results.
Common Causes of
Breathlessness
Cardiac
Further Examinations/Tests
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Possible Diagnoses/Reasons
for Breathlessness
If raised BNP refer via choose and book to one stop heart failure
clinic to diagnose or exclude heart failure (echo and specialist
opinion together)
Consider 24/7 day tape if patient has intermittent symptoms –
palpitations/falls/dizziness
Consider Echocardiogram if murmur/abnormal BNP/abnormal
chest x-ray/abnormal ECG
Consider stress/exercise echocardiography if exertional dyspnoea
along with an assessment of cardiovascular risk
Consider using GSTFT Cardiology Choose & Book advice and
guidance option for opinion on further investigations
Referral to diagnostic spirometry if FEV1 < 80% predicted
Consider using the respiratory single point of referral for advice
and guidance on further investigations and onward management
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Heart failure
Angina-equivalent
Valve disease
Arrhythmia
Ischemic heart disease
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Respiratory
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Mental Illness and
Addiction
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GAD 7 and PHQ9
Addiction assessment
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Obstructive airways disease
ILD
Obesity
Scoliosis
Neuromuscular
pulmonary hypertension
hyperventilation
poor home air quality eg
damp/no ventilation
Anxiety and/or depression
hyperventilation
Fitness and Lifestyle
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Audit score for alcohol
Eat Well Plate and Food Diary (template on Southwark Intranet)
If available use 7 day pedometer assessment for patients with
MRC 1-3
Use Short Physical Performance Battery (SPPB), including the 4
Meter Gait Speed Test to assess frailty with patients with MRC 4-5
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low levels of fitness
obesity
smoking/alcohol
Use choose and book advice and guidance option to get further
opinion from a nephrologist or haematologist before testing or
referral
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Malignancy
Deficiency anaemia
Renal Failure
Chronic disease anaemia
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Anaemia/Kidney
Disease
STEP 5
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Consider Contributing Factors to Breathlessness
There may be more than one contributing factor to breathlessness.
Breathlessness is likely to be multi-factorial without a single specific diagnosis. If a physical cause is identified still
consider whether psychological factors are contributing to or a consequence of the breathlessness.
Order each of the possible contributory factors for the chronic breathlessness (Cardiac/Respiratory/mental
Illness/Fitness and Lifestyle/Anaemia and Kidney Disease) this allows prioritisation of investigations, treatments
plans and referrals.
Revisit relative weighting to each of the possible contributory factors for the breathlessness at each review.
If there are no obvious cause(s) of breathlessness identified it is likely that fitness and lifestyle factors need to be
addressed. If you have worked through this algorithm with your patient and come to this conclusion it is
reasonable now to refer for therapeutic interventions for quitting smoking, alcohol reduction, weight
management, physical activity improvement and psychosocial support. Collaboratively agree goals/care plan.
Guideline Adapted from IMPRESS Breathlessness Algorithm http://www.impressresp.com/index.php?option=com_docman&Itemid=82
Guideline Agreed July 2014 (Review date: January 2015)