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Respiratory emergency: a recent case study

Wendy Johnson
BSc(Hons) RN DipN NPDip
Nurse Consultant in Primary Care
Tooting NHS
Walk-In Centre
Hon Senior Lecturer
RCN Development Centre
South Bank University

Helen Ward
BSc(Hons) RN NPDip PGCEA
Senior Lecturer
RCN Development Centre
Nurse Practitioner
Tooting NHS
Walk-In Centre

Mrs White, a 50-year-old Caucasian woman, presented to the Walk-In Centre in a distressed state. She had sharp leftsided chest pain, acute onset of shortness of breath, and had coughed up some blood. She was very agitated and frightened that she was dying.

This is an emergency situation. A careful and urgent assessment and initiation of emergency treatment are mandatory. Oxygen should be administered immediately before an assessment of the patient's condition is made. Oxygen is used to decrease the work of breathing necessary to maintain a given oxygen tension. This may relieve some of the patient's distress. High-flow oxygen with 85% inspired oxygen is almost always required. This should be administered through a face mask with reservoir bag at a flow in excess of 12 litres/min. 
Even in patients with chronic airflow limitation, high- concentration oxygen therapy is advised until they can be formally assessed in hospital.(1) 
Although concern is often expressed regarding oxygen- induced reduction of respiratory drive, hypoxia can kill, and is far more serious than carbon dioxide retention. Position the patient in an upright sitting position to maximise ventilation. Try to calm them and reduce their anxiety. Once the patient has been stabilised, the underlying cause of the chest pain and dyspnoea can be established.

Immediate observations reveal that she is pale but not cyanosed and is taking very rapid shallow breaths. She is fully conscious and orientated. Vital signs show a rapid respiratory rate of 40/min, tachycardia (heart rate 130bpm), pyrexia (temperature 38.5ÞC) and hypotension (blood pressure 90/60mmHg). She is overweight.

Acute breathlessness is a common medical emergency (Table 1). The effort required for breathing makes it difficult for the patient to provide a history, and questioning may make the matter worse. You may therefore have to rely on information from an accompanying relative.

[[NIP05_table1_55]]

A structured approach will ensure that immediate life-threatening causes are identified and treated. The key questions to ask at this stage are:

  • How long have you been experiencing your current symptoms?
  • What were you doing before becoming short of breath?
  • Is this the first time you have experienced anything like this?

Focused history-taking should eliminate trauma, inhalation of a foreign body, anaphylaxis following an insect bite or sting, ingestion of medication, or other potential allergens such as shellfish, an acute asthma attack or other pre-existing medical conditions.

At this stage the history reveals that Mrs White has had a 36-hour history of chest pain that has gradually been getting worse. This has been followed by a sudden onset of shortness of breath with haemoptysis over the last two hours. She has just returned from Australia two days ago following a visit to her daughter. She slept for most of her journey. She has never experienced anything like this before.

In an emergency situation it may not be possible to get a full holistic history from your patient.

As Mrs White becomes less distressed once she is breathing oxygen, she tells us that she has been taking HRT for the last three years. Details of past medical history and family history reveal that her mother has recently suffered a stroke. Psychosocial history reveals that she longer smokes but smoked 5-10 cigarettes a day for 15 years.

Physical examination will help to confirm a diagnosis. Observe the thorax and lungs for respiratory rate, depth and rhythm. Observe respiratory effort and any use of accessory muscles.
 
Assessment of chest expansion reveals unequal expansion of the chest, decreased on the left side. Palpation of the chest reveals increased vocal fremitus on the left side due to an increase in lung density. Auscultation reveals reduced air entry on the left side with some wheezes. A pleural friction rub can also be heard during both inspiration and expiration owing to inflammation of the pleural linings.
Mrs White is displaying typical signs of a moderate-sized pulmonary embolism - chest pain, shortness of breath and haemoptysis. However, there are no signs of deep vein thrombosis (DVT) - examination of both calves revealing varicose veins but no other abnormality.

Urgent hospital admission will be required for anyone suspected of having a pulmonary embolus. Alert medical colleagues within the practice and call an ambulance. Intravenous access is necessary, so if you have the facilities, arrange cannulation now.
 
In an acute situation you are unlikely to initiate investigations yourself, although an electrocardiogram may help to confirm diagnosis and exclude other causes, such as myocardial infarction or pericardial disease. Typical changes in pulmonary embolism include an S-wave in lead I, Q-wave and an inverted T-wave in lead III. 
Analgesia may be administered immediately, and paracetamol is often sufficient. 
Pulmonary embolism (PE) is an important condition because it is potentially fatal, often preventable and sometimes treatable. The annual incidence of DVT and/or PE is one in 2,000 in the general population,(3) with factors such as immobility, recent surgery and clotting abnormalities increasing the risk (Table 2). Emboli may occur following periods of inactivity such as long-haul flights. Emboli circulate in the blood to the right side of the heart and enter the lung via the pulmonary artery. If the clot is not dissolved within the lung, it may occlude the pulmonary artery and obstruct the blood flow and perfusion to the lung. This can be a life-threatening condition.

[[NIP05_table2_56]]

Recent increased awareness of the risk of DVT associated with long distance travel means that practice nurses should routinely incorporate advice on its prevention into travel health promotion (Table 3).

[[NIP05_table3_56]]

Contact
Tooting NHS
Walk-In Centre
Clare House
St George's Hospital
London SW17 0QT

References

  1. Wardle T. Respiratory emergencies. In: Greaves I, Porter K, editors. Pre hospital medicine. London: Arnold; 1999.
  2. Hopcroft K, Forte V. Symptom sorter. Oxford: Radcliffe Medical Press; 1999.
  3. Van den Belt AGM, Prins MH, Lensing AWA, et al. Fixed dose low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. (Cochrane Review). In: The Cochrane Library, issue 4. Oxford: Update Software; 2000.
  4. Advanced Life Support Group. Acute medical emergencies: the practical approach. London: BMJ Books; 2001.
  5. McIntosh I. Travellers' thrombosis and its prevention. Prescriber 5 March 2002:18-25.

Further reading
Bickley L. Bates' Guide to physical examination and history taking. 7th edn. Philadelphia: Lippincott; 1999.
Kilner T, Wilkinson R. Medical emergencies. In: Dolan B, Holt L, editors. Accident and emergency nursing - theory into practice. Edinburgh: Baillière Tindall; 2000.