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Red flag symptoms: Breathlessness, investigations and when to refer

Red flags to be aware of in patients presenting with breathlessness, possible causes and when to refer.

Severe breathlessness can be a frightening, disabling experience (Photo: SPL)
Severe breathlessness can be a frightening, disabling experience (Photo: SPL)

Red flag symptoms

  • Associated chest pain or possible cardiac symptoms (such as palpitations)
  • Sudden onset with persistent symptoms
  • Visible physical signs (cyanosis, unable to speak in sentences, confusion, agitation, leg swelling)
  • Noisy breathing (stridor, audible wheeze, persistent cough)
  • History of prolonged immobility, trauma or previous complications with breathing
  • Onset of or worsening orthopnoea

Severe acute or prolonged breathlessness can be a frightening, disabling experience and may create a significant sense of urgency.

Patients with chronic pulmonary or cardiac conditions may be used to a certain degree of breathlessness at times, but any deterioration could quickly become a serious and acute complication.

The speed of onset and immediate impact on the patient may be the most important details to establish the medical urgency and to estimate the risk of problematic progression.

Possible causes

  • Exacerbation of chronic underlying conditions (COPD, chronic bronchitis, emphysema, asthma, cystic fibrosis, heart failure)
  • Sudden airway trauma (foreign body aspiration, excessive secretions, anaphylaxis, thromboembolism, pneumothorax) or cardiac trauma (MI)
  • Complication of parenchymal lung disease (for example, fibrosing alveolitis, sarcoidosis, pneumoconiosis), asbestosis, lung cancer or metastases
  • Acute infection (pneumonia, epiglottitis, meningitis)
  • Other fundamental system failures (severe anaemia, liver or renal failure, metabolic disturbances, such as in diabetes; terminal phase of life)
  • Psychogenic breathlessness/hyperventilation
  • Rare causes, such as Guillain-Barre syndrome, myasthenia gravis, multiple sclerosis, toxicity (carbon monoxide, NSAIDs)

History

If the patient is acutely distressed it may be necessary to keep the history from the patient focused, while more comprehensive details could be gathered from other people, such as family members or carers.

Any activity or exposure before the onset of symptoms could be relevant - eating could cause breathlessness due to food bolus or allergy; physical activity could have triggered a pneumothorax or cardiac event. Although very unlikely, a carbon-monoxide problem at the patient's house is possible so you should be mindful of your own safety when on a home visit to a breathless patient. 

Details about previous episodes of breathlessness, possible chronic conditions, known allergies and regular medications are essential. There has been a drive in recent years to assess chronic breathlessness more systematically, for example via the MRC breathlessness scale, so, changes there may be important to pick up and acknowledge.

A calm but decisive approach can be important to help reassure the patient. Keep a low threshold of calling for early additional help (emergency ambulance) if you have to consider possible airway compromise, which may acutely worsen the case if not identified and dealt with quickly.

Estimate respiratory rate and effort, use of accessory muscles or any dependency on position. Check for cyanosis, cardiovascular state, pleuritic pain, pulse, blood pressure and temperature.

Pulse-oximeters are a very affordable and useful portable piece of equipment to check and monitor oxygen saturation levels and pulse rate. But keep in mind that peripheral vascular shut-down can lead to wrong readings, and in young children you may have to use it on the big toe rather than a finger to get a reading at all.

Listen for breathing noises and cough, as well as any problems in speaking in whole sentences.

Examine the lungs on at least three levels with auscultation (careful if there seems to be a "silent chest") and palpitation. Check for abnormal heart sounds, possible increased JVP, peripheral oedema and calf swelling or tenderness.

Consider a Wells score assessment to estimate the probability of DVT and pulmonary embolism if you are concerned about this. Children sometimes complain of abdominal pains in cases of pneumonia and may not initially reveal obvious abnormal findings over the lungs.

Consider peak flow measurements, if this is possible and practical – obviously you do not need to do this if the patient is struggling with normal breathing at the time. It can be most useful if there are previous reference readings from the patient, for example, as part of their asthma (self-)monitoring.

Some patients who have already got inhalers may have used them excessively in an attempt to get symptom relief; be aware that a subsequent tachycardia from β2 agonist overuse can create more anxiety and discomfort. If you feel that some immediate salbutamol may be indicated, a good dose of 10 puffs, ideally given via a spacer device, is almost as effective as a nebuliser.

There have been concerns that giving (high-dose) oxygen to patients with COPD or emphysema and type II respiratory failure could worsen their unfavourable carbon dioxide and low pH situation because it may cause further accumulation of carbon dioxide and affect the the respiratory drive. However, the risk of increasing respiratory failure through oxygen in an emergency situation is small compared with the potential benefit, so the application should not be withheld.

Depending on the history and findings, some baseline investigations may be needed (chest X-ray, ECG, blood test for anaemia, inflammation and infection, metabolic dysfunction, troponin; consider D-dimers if available and indicated).

Keep a very low threshold for deciding where the safest place for the patient is, and where further monitoring will be available. Any factors causing immediate concern would suggest a transfer to A&E.

This also applies if exclusive tests are needed promptly, such as venometer/CT pulmonary angiogram, VQ scan or blood gases. Other investigations, such as echocardiogram, exercise ECG or pulmonary CT may be required, but rarely acutely.

When to refer

  • Sudden onset and continuing symptoms in usually well and/or young patients.
  • Concern about possible fundamental acute underlying cause (pulmonary embolism) or poorly controlled chronic pulmonary condition (asthma, COPD).
  • Need for immediate further investigations or potentially life-saving treatment.

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  • Dr Jacobi is a GP in York

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