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Sub-Acute Breathlessness Lauren Merriman-Jones 1 October 2024Use code CBOSCECREW24 at checkout on geekyquiz.com for 10% off OSCE flashcards, OSCE stations and knowledge bundles. Lesson Objectives: 1. Recap causes of breathlessness and sub-acute breathlessness 2. Improving ability of respiratory history (linking questions to causes of sub-acute breathlessness) 3. Review of Asthma and COPD management in both acute and chronic settings 4. Explanation of peak flow and inhaler techniqueHow many causes of SOB can you name? Causes of breathlessness Respiratory disease: Asthma, COPD, ILD, PE, TB, Pneumonia, Pneumothorax, Cancer (in the larynx, lung or pleura) Cardiac disease: AF/arrythmias, valvular heart disease, Pulmonary oedema (cardiac failure), ACS Systemically: Anaemia, Renal failure, Metabolic acidosis, Liver cirrhosis, Sepsis, Medication side effects, Illicit drug usage, Anxiety, Myasthenia gravis What is sub-acute breathlessness? - Subacute breathlessness is defined as SOB developing over hours or days - Acute – minutes - Chronic – weeks to months What are causes of sub-acute breathlessness? - Asthma - COPD - Pneumonia – hospital acquired (HAP) and community acquired (CAP) - Lower Respiratory Tract Infection (e.g. bronchitis and pneumonia) - Upper Respiratory Tract Infection - Tuberculosis Respiratory History (Sub-Acute Breathlessness) SOCRATES for breathlessness ● Site (not relevant) ● Onset – When did this start? Was it sudden or gradually? ● Character – How do they describe being SOB? Do they feel as if they cannot breathe? Tight chested? ● Radiation (not relevant) ● Associated symptoms – Are they experiencing any other symptoms? ● Timing – Has the SOB changed since the start (ie getting worse/better/steady)? ● Exacerbating and relieving factors – Does anything make the breathlessness worse or better (e.g. exercise, cold weather, coughing)? ● Severity – How severe would they say the breathlessness is 1-10 scale? (relevant for exacerbations)Respiratory History (Sub-Acute Breathlessness) Review of respiratory symptoms alongside the SOB – apply SOCRATES to all - Cough - Production/Unproductive, sputum colour, volume, BLOOD? - Productive - ?COPD(IE), pneumonia, TB - Unproductive - ?URTI, COPD, asthma, TB - Wheezing - ?asthma, COPD - Chest pain - ?LRTI, pneumonia, TB - Red Flag Symptoms - Fever (TB, pneumonia, IECOPD) - Weight loss (TB, end stage COPD) - Fatigue (TB, COPD, pneumonia) - Haemoptysis (TB, pneumonia) Respiratory History (Sub-Acute Breathlessness) ● ICE ○ Patients may reveal information that they may not have in other lines of questioning (e.g. personal/family history, ”embarrassing” symptoms, someone else they know has taken ill) ○ Having time to understand patient’s worries or concerns improves the doctor-patient relationship ○ Helps you manage their expectations of what may be to come (e.g. they may think they just have new SOB from a cold but there is an underlying serious problem) ● Past Medical History ○ Always enquire about specific respiratory conditions first - for example, history of asthma/COPD/breathing problems – then ask more broadly (key emphasis on DM, previous malignancies, immunosuppression, atopy history or cardia ○ Recent hospital visits/surgeries & how long was their stay (increases risk of HAP) ○ Allergies? Do they carry an epi-pen? What is the typical reaction to allergen? Respiratory History (Sub-Acute Breathlessness) - Drug History - Prescribed, OTC and specifically enquire about contraception (it is missed often, especially LARCs) - Have they had any side effects? - Have they had any trouble taking their medication regularly/as prescribed? - Allergies (if not asked earlier) - Family History - Ask about specific following: lung disease, CVD, VTE or malignancies - Then enquire about less specific causes - If yes, age they developed disease - If yes and member has passed away, enquire about age of death and cause Respiratory History (Sub-Acute Breathlessness) - Social History - Smoking – never ask “do you smoke” always ask, “have you ever smoked?” - For anyone who has ever smoked, calculate pack year history (20 cigarettes in a pack for reference) - Ask about e-cigarettes and vaping too - Alcohol – frequency, type and volume PER WEEK (can ask them how much do you drink a day and x 7) - Recreational drug use (IVDU increases risk of TB and smoking cannabis can increase risk of COPD) - Occupation (occupational exposure, e.g. infectious disease or CAP) - Travel history (India, Pakistan, Romanian, Bangladesh and Somalia have high rates of TB, ask about vaccination status too. Legionella pneumonia = in AC units due to poor maintenance.) - Activities of Daily Living – How are they managing with their SOB? Is it stopping them doing regular activities (from working or going to the shops to bathing and getting dressed) Respiratory History (Sub-Acute Breathlessness) - Systems Review – may or may not be relevant to their condition (always screen for sepsis) - Systemically – fever, fatigue, no appetite, night sweats, weight loss - CV – chest pain - GI – reflux symptoms (always say burning pain when eating), altered bowel habits - ENT – rhinorrhoea, blocked nose - Skin - eczema - Neurological - dysphagia Respiratory History (Sub-Acute Breathlessness) Closing the history - Relay important points back to the patient to check you have got all the information and asked if you have left anything out - Ask if they have any questions for you (crucial for OSCE) - Thank them for their time - WASH HANDS Practice History A 76 year old presents to his GP with breathlessness that developed 2 weeks ago. He has the occasional productive cough for the past few months and is afebrile. He has been smoking since he was 17. He is known to the smoking services but has not engaged very much. He has no other medical or drug history of note. What is the most likely diagnosis from the following options: A. Pneumonia B. URTI C. COPD D. Asthma E. Tuberculosis Practice History A 76-year-old presents to his GP with breathlessness that developed 2 weeks ago. He has the occasional productive cough for the past few months and is afebrile. He has been smoking since he was 17. He is known to the smoking services but has not engaged very much. He has no other medical or drug history of note. What is the most likely diagnosis from the following options: A. Pneumonia B. URTI C. COPD D. Asthma E. TuberculosisManagement of Asthma and COPD Asthma management – chronic (day-to-day) Stepwise Management: * MART = Combination of ICS 1. Short-acting beta agonist (SABA) and LABA with a single inhaler. The 2. SABA + Low-dose inhaled corticosteroid (ICS) LABA is usually as formoterol. 3. SABA + ICS + Leukotriene receptor antagonist (LTRA) 4. SABA + ICS + Long-acting beta agonist (LABA) (+/- LTRA) 5. SABA + Maintenance and reliever therapy (MART) that has low-dose ICS (+/- LTRA) 6. SABA + medium-dose ICS MART (+/- LTRA) Budesonide dose of ICS (or equivalent): - Low dose = <400 micrograms 7. SABA +/- LTRA with one of the following: - Medium dose = 400-800 micrograms (a) High dose ICS by itself (no LABA) - High dose = >800 micrograms (b) Long-acting muscarinic receptor antagonists (LAMA) or theophylline trial (c) Asthma expertise advice Asthma management – Asthma exacerbation Features of asthma exacerbation (attack): Severe and worsening SOB, wheeze, cough, no or little response to salbutamol inhaler (SABA) How we categorise an asthma exacerbation: Asthma management – Asthma exacerbation 1. Oxygen – for hypoxaemia (<94%) give supplementary oxygen and if acutely unwell 15L of supplemental via non-rebreather mask to maintain 94-98% SpO2 2. Bronchodilation with SABA – use high dose SABA (e.g. salbutamol), this should be nebulised for life-threatening attack (inhaler or oxygen-driven nebuliser for everyone else) 3. Corticosteroid – 40-50mg prednisolone orally that needs to be continued until 5 days after attack (continue regular inhaler ICS as well) – IV hydrocortisone if patient cannot swallow (whilst in hospital) 4. Stepping up drugs – Ipratropium bromide (severe/life-threatening) ▯ IV magnesium sulphate (severe/life-threatening) ▯ IV aminophylline (need senior support) 5. No response to above management – Senior critical care support, escalation to ITU or HDU (can include intubation and ventilation, and ECMO in extreme circumstances)COPD management – day-to-day General points: - Stopping smoking (or offering NRT) - Pulmonary rehabilitation (key for those with very severe daily SOB) - Annual flu vaccines and one-off pneumococcal vaccine Alternative drugs: ● Oral theophylline (when bronchodilators have proved ineffective, or they cannot use inhalers) ● Azithromycin prophylatic (consistent infective exacerbations despite optimum treatment) ● Mucolytics (breaks up mucus to reduce sputum production if troublesome) ● Rescue packs for COPDIE (will have oral corticosteroids and oral antibiotics) ● minimum of 15 hours a daywhen breathlessness persists, oxygen for COPD management - COPD exacerbation Features of exacerbation: worsening of SOB, wheeze and cough (+ increase in sputum production) Moderate exacerbation management (can be managed at home): - Increase usage of bronchodilator use +/- nebuliser - Prednisolone 30mg for 5 days - Antibiotics should only be given if purulent sputum or signs of pneumonia (amoxicillin, clarithromycin or doxycycline) COPD management - COPD exacerbation When should we admit patients for COPDIE? - Symptoms come on very suddenly - No response to initial treatment - Severe breathlessness - Acute confusion - Cyanosis - SpO2 <90% - Other significant comorbidity (e.g. cardiac disease) COPD management - COPD exacerbation 1. Oxygen Therapy (need to keep in mind hypercapnia) – aim for 88- 92% SpO2 with 28% Venturi mask at 4L/min 2. Nebulised bronchodilator - either salbutamol or ipratropium 3. Steroid therapy - can escalate to IV hydrocortisone 4. No response = step up to IV theophylline 5. Type 2 respiratory failure develops = non-invasive ventilationInhaler and Peak Flow Technique Inhaler Technique Preparation 1. Hold the inhaler upright. 2. Remove the cap from the inhaler and inspect to make sure there is nothing inside the inhaler mouthpiece. 3. Shake the inhaler well. Inhalation 4. Sit or stand up straight and slightly tilt your chin up. This position helps the medication to better reach the lungs. 5. Breathe out gently and slowly away from the inhaler until your lungs feel empty. 6. Put your lips around the mouthpiece of the inhaler to create a tight seal. 7. Start to breathe in slowly and steadily whilst at the same time pressing the canister on the inhaler once. 8. Continue to breathe in slowly until your lungs feel full. 9. Remove the inhaler from your mouth and seal your lips. 10. Hold your breath for 10 seconds, or as long as you are comfortably able to. 11. Breathe out gently, away from your inhaler. Final steps 12. Once you have finished using your inhaler, replace the cap. If you’ve used an inhaler that contains steroids, rinse your mouth with water to reduce the chance of side effects. Spacer Technique ● If using a spacer: • Shake the inhaler well and attach on to the end of the spacer. • Seal your lips around the mouthpiece. • Squirt one puff of the inhaler into the spacer. • Take a slow deep suck in (as if sucking on a straw) and then 'blow' out. Repeat five times without taking your lips from around the mouthpiece (with most spacers you should hear the valve clicking). • Repeat all steps if further puffs are needed. Peak Flow Meter Technique 1. Use a disposable mouthpiece on the end of the meter (or use a clean reusable one) 2. Red arrow should be at the bottom of the meter 3. Whilst sitting upright or standing, take in the deepest breath you can 4. Make a seal over end of mouthpiece and blow as hard as you can 5. Record the number on a sheet of paper 6. Repeat this until you have 3 scores (with short breaks in between) 7. Record the highest of the 3 ONLYAny questions?