Why acute breathlessness in a young adult matters
A young person who can only speak a few words at a time is in danger. Young patients compensate well and then tire suddenly, so judge how sick she is before you work out why, and keep judging after each treatment.
What to ask in the history
- How fast it came on, and what she was doing
- Possible triggers: a cold, allergens, exercise, smoke, a new medicine
- Wheeze, cough, sputum, fever, chest pain
- Previous episodes, and any diagnosis of asthma or allergy
- Inhalers: which ones, how often she has needed them in the last days
- Previous hospital or intensive care admissions for breathing
- Contraceptive pill, recent travel or immobility, a swollen leg
- Smoking and pets
Red flags
- Cannot finish a sentence
- Tiring, drowsy or confused
- A quiet chest despite hard work of breathing
- Low oxygen saturation or blue lips
- A blood gas that is not reassuring in someone working this hard
- Very fast or slowing pulse, or low blood pressure
- A previous intensive care admission
What to examine
- How she looks: can she speak, is she using her neck and shoulder muscles
- Breathing rate and oxygen saturation
- Chest movement, position of the trachea, percussion
- Breath sounds: wheeze, crackles, or a silent chest
- Pulse, blood pressure, conscious level
- Peak flow if she can manage it
- Legs for swelling or tenderness; skin for rash or swelling of the lips
First investigations
- Pulse oximetry, continuously
- Arterial blood gas
- Peak expiratory flow, before and after treatment if she can do it
- Chest X-ray
- Full blood count, electrolytes including potassium
- ECG
- Tests for a clot only if the picture points that way
Differential diagnosis of acute breathlessness in a young adult
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Lung
- Pneumonia
- Pneumothorax
- Pulmonary embolism
Airways
- Acute asthma
- Anaphylaxis
- Upper airway obstruction
Heart
- Myocarditis
- Arrhythmia
Other
- Metabolic acidosis (for example diabetic ketoacidosis) driving fast breathing
- Hyperventilation from anxiety, only once the others are excluded
Common mistakes
- Being reassured when the wheeze goes quiet: it can mean too little air is moving.
- Reading a blood gas as fine because nothing is very abnormal, in a patient who is working this hard.
- Calling it anxiety before excluding the physical causes.
- Not reassessing after each treatment.