Case scenario:

You saw a 45 year old lady who presented with acute dyspnea for the past 2 days
associated with fever and cough. She has background history of childhood asthma and
hypertension.

1. List the common causes of acute onset of dyspnoea.

2. Describe the relevant history and its significance.

HISTORY REASON

Time course Sudden or gradually?

Precipitating Events leading up to current episode

factor or event -Recent symptom/specific trigger?
Associated  Chest pain – ACS, Pneumothorax,PE
symptom  Trauma
 Fever – infection
 PND – COPD/Heart Failure
 Hemoptysis – PE, TB, malignancy
 Underlying anemia/ hematological disorder
 Cough and sputum? Character?

Past history  New onset? Previous similar episode?

 Pre-existing medical condition eg asthma -exacerbation
Prior intubation  History of ET intubation due to SOB
 High risk of severe disease and need intubation
Medication  Recent changes in medication or dosing
 May indicate severity
 Compliance
Tobacco and  Tobacco- COPD, malignancy
drug  Drug- intoxication eg opioid or aspirin
Psychiatric  Organic causes MUST be ruled out first
condition  Psychogenic dyspnea eg. anxiety attack

3. Outline symptoms and signs of respiratory distress

SYMPTOMS SIGNS
 Shortness of breath  Tachypnea
 Lethargy  Tachycardia
 Use of accesory muscle
 Recession (Subcostal,supraternal,intercostal)
 Cyanosis
 Stridor / wheezing
 Grunting
 Nasal flaring
4. Describe the features of moderate, severe and life-threatening asthma.

5. Demonstrate how would you advice a patient to perform a peak flow meter
assessment.

6. What are the relevant investigations in acute dyspnoea and give reasons why.

i. Pulse Oximetry - To check the severity of hypoxia

ii. Peak Flow Measurement
iii. Aids in the diagnosis of Asthma/COPD
iv. Monitoring of treatment
v. ECG - To rule out cardiac causes such as ACS, pulmonary embolism, cardiac
arrhythmia
vi. Full Blood Count
vii. To rule out anemia, infective causes
viii. Arterial Blood Gases - Respiratory failure (Type 1 or 2)
ix. Serum D-Dimer - To rule out Pulmonary Embolism
x. Renal Profile - Look for electrolyte imbalance (Mg, K)
 xi. Chest X-Ray - TRO lung pathology: pneumonia , pneumothorax or lung collapse are
suspected
xii. Sputum culture and sensitivity - to look for the infective organism

7. Outline the pharmacological treatment in asthma exacerbations.

Consider for discharge if PEF

improvement more than 75%

8. List the criteria of admission in asthma exacerbation.

• All patients with severe, life threatening asthma and those with PEF <75% one hour
after initial treatment.
• Factors may considered for admission
‐ Persistent symptoms
‐ Previous near-fatal asthma attack
‐ Living alone / socially isolated
‐ Psychological problems
‐ Physical disability or learning dificulties
‐ Asthma attack despite recent adequate steroid treatment
‐ Pregnancy

9.