Why sudden breathlessness at night matters
Waking at night fighting for breath has a short list of causes: fluid on the lungs, narrowed airways, a clot or an infection. Their treatments differ, so a quick focused examination and a few bedside tests have to sort them out while you support her breathing.
What to ask in the history
- How it started, and how she is lying or sitting now
- Previous episodes, how many pillows she sleeps on, breathlessness on exertion, ankle swelling
- Cough, frothy or pink sputum, wheeze, fever
- Chest pain, palpitations
- Known heart disease, blood pressure, diabetes, kidney disease
- Medicines and any missed doses
- Asthma or other lung disease, smoking
Red flags
- Cannot lie flat or finish a sentence
- Low oxygen saturation
- Low blood pressure, cold clammy skin, confusion
- Chest pain
- A new irregular or very fast pulse
What to examine
- Sit her up; breathing rate and saturation
- Pulse rate and rhythm, blood pressure
- Jugular venous pressure
- Heart sounds, added sounds and murmurs
- Chest: crackles, wheeze, dullness
- Ankle and sacral swelling; temperature of hands and feet
First investigations
- ECG
- Chest X-ray
- Blood gas
- Troponin, and a natriuretic peptide if available
- Full blood count, kidney function, electrolytes, glucose
- Echocardiogram
Differential diagnosis of sudden breathlessness at night
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Lung
- Asthma or COPD flare
- Pneumonia
- Pulmonary embolism
Heart
- Acute heart failure with fluid on the lungs
- Myocardial infarction
- Arrhythmia
- Valve disease
- Very high blood pressure
Other
- Severe anaemia
- Fluid overload from kidney failure
- Anxiety, once the others are excluded
Common mistakes
- Calling wheeze asthma without thinking of the heart.
- Treating every breathless patient with nebulisers alone.
- Not using the ECG to look for what set it off.