🩺 Shortness of Breath

Shortness of breath (dyspnoea) is a subjective sensation of breathing discomfort that can arise from cardiac, respiratory, metabolic, or psychological causes. It is a common cause of both acute hospital admissions and chronic primary care consultations. Rapid assessment to determine the need for respiratory support (AIS/NIV) is vital in acute cases. Diagnosis is often made through a combination of history, physical signs, and radiological imaging.

Establish the onset (sudden vs gradual) and duration. Sudden onset suggests PE, pneumothorax, or acute LVF, while gradual suggests COPD, anaemia, or chronic heart failure. Enquire about associated symptoms like cough, sputum production (colour/consistency), haemoptysis, and chest pain. Occupational history (asbestos/dust exposure) and smoking history are critical. Ask about nocturnal symptoms and the number of pillows used, as well as recent travel or calf pain (VTE risk).

Assess the work of breathing, including the use of accessory muscles and the ability to speak in full sentences. Observe for cyanosis (central/peripheral) and clubbing (indicative of malignancy, bronchiectasis, or fibrosis). On percussion, a dull note suggests effusion or consolidation, while hyper-resonance suggests pneumothorax. Auscultate for wheeze (obstructive), crackles (oedema or fibrosis), or bronchial breathing (consolidation). Check for peripheral signs like JVP height and ankle oedema.

Acute: Pulmonary Edema, Asthma/COPD exacerbation, PE, Pneumonia, Pneumothorax. Chronic: Heart Failure, COPD, Interstitial Lung Disease, Anaemia, Anxiety/Hyperventilation.

Stridor or upper airway obstruction signs; inability to speak in sentences; tracheal deviation (tension pneumothorax); accessory muscle use and exhaustion; silent chest in a severe asthma attack.

First-line tests include pulse oximetry, 12-lead ECG (to exclude cardiac triggers), and a Chest X-ray. Bedside peak flow is useful if asthma or COPD is suspected. Blood tests should include a FBC (anaemia/infection), U&Es, and NT-proBNP if heart failure is suspected. Arterial Blood Gas (ABG) is required if the patient is acutely unwell or if Type 2 Respiratory Failure is suspected. CTPA or Spirometry may be required for more definitive diagnosis.

Always differentiate between acute and chronic onset. Orthopnoea and Paroxysmal Nocturnal Dyspnoea (PND) are highly specific for heart failure. In patients with COPD or Asthma, a 'silent chest' is a sign of life-threatening obstruction. Use the MRC Dyspnoea scale to quantify the impact on the patient's daily life in chronic settings. Point-of-care ultrasound (POCUS) is increasingly used in ED to look for 'B-lines' (oedema) or lung sliding (pneumothorax).

Covers key respiratory and cardiovascular components of the MLA. Includes interpreting ABGs and understanding the indications for oxygen therapy vs. ventilatory support (NIV/CPAP). Focuses on the differentiation of obstructive vs. restrictive patterns.