Emergency Medicine

BREATHLESS PATIENT

72 General Medical Emergencies

9 Perform bedside lung function testing for PEF, FEV 1 and FVC to compare with

prev ious respirator y f unction tests, and to follow t he response to treatment.

10 Request a CXR which may show hyperinf lation, bullae, atelectasis, consoli-

dation, pneumothorax, heart failure or a lung mass.

MANAGEMENT

1 Commence controlled oxygen therapy initially at 28% via a Venturi mask if

there is evidence of chronic carbon dioxide retention, with a raised PaCO 2

and bicarbonate. Aim for an oxygen saturation over 90%.

(i) Otherwise give higher dose 40–60% oxygen via face mask to treat

hypoxaemia. Watch out for deterioration and a rising PaCO 2.

2 Give salbutamol 5 mg via a nebulizer for bronchospasm repeated as needed,

and add ipratropium (Atrovent™) 500 g to the initial nebulizer then

6-hourly.

3 Give prednisolone 50 mg orally or hydrocortisone 200 mg i.v. if unable to

swallow, for bronchospasm and or if on long-term inhaled or oral steroids.

4 Treat infection with amoxicillin 500 mg orally t.d.s., or doxycycline 100 mg

orally b.d. both for 5 days.

5 Give frusemide (f urosemide) 40 mg i.v. if heart failure is suspected.

6 Admit under the medical team.

7 Call urgent senior ED doctor help if there is exhaustion, agitation or confu-

sion; or a rising PaCO 2 and a falling pH. Involve the intensive care team.

(i) Commence non-invasive ventilation (NIV) if there are trained

and experienced staff to supervise.

Pneumothorax

DIAGNOSIS

1 Spontaneous pneumothorax that occurs in an otherwise healthy patient

with no lung disease, particularly in taller people, is designated a ‘primary’

pneumothorax.

2 Spontaneous pneumothorax that occurs in a patient with chronic lung

disease (CLD) is termed a ‘secondary’ pneumothorax, and is associated with

asthma, emphysema, fibrotic or bullous lung disease including cystic

fibrosis and Marfan’s syndrome.

(i) In addition, this includes patients aged over 50 years who may

have unrecognized underlying lung disease.

3 Spontaneous pneumothoraces are also much more common in smokers.

4 Pneumothorax may be due to both penetrating or blunt trauma.

(i) See p.231 for discussion on the management of traumatic

pneumothorax.