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Breathlessness - Management
How should I manage someone with acute breathlessness waiting for emergency admission?

  • Sit the person up.
  • If the person has an oxygen saturation of less than 92%, give oxygen and continuously monitor their oxygen saturation levels while waiting for transfer to hospital.
    • ONLY USE A 28% VENTURI MASK AT 4 L/MIN FOR PEOPLE WITH SUSPECTED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), morbid obesity, a chest wall deformity, or a neuromuscular disorder. This is because they are at risk of hypercapnic respiratory failure.
    • For other people who are acutely ill, use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target oxygen saturation of 94–98%.
  • Identify and treat people with clinical features of:
    • Silent myocardial infarction: give aspirin 300 mg.
    • Pulmonary oedema.
      • Give an intravenous diuretic, opioid, and anti-emetic (for example furosemide 40 mg to 80 mg, diamorphine 2.5 mg to 5.0 mg, and metoclopramide 10 mg).
      • Also give a nitrate, either sublingual or buccal (for example glyceryl trinitrate [GTN] spray, two puffs).
    • Supraventricular tachycardia (SVT). Attempt to terminate the arrhythmia, using a valsalva manoeuvre or carotid sinus massage. For further information, see the CKS topic on Palpitations.
      • Valsalva manoeuvre — ask the person to breathe out against a closed nose and mouth.
      • Carotid sinus massage — do not attempt this if the person is elderly, or has ischaemic heart disease, a carotid bruit, or a history of stroke or transient ischaemic attack. Only attempt one side at a time. Ensure that a defibrillator is available, as (very rarely) terminating an SVT can provoke other arrhythmias. Ideally, continuously monitor by electrocardiography (ECG), during the procedure as well as afterwards.
    • Acute severe asthma (peak expiratory flow rate less than 50% of predicted).
      • Give a bronchodilator (for example nebulized salbutamol 5 mg, or repeated doses of a metered-dose inhaler via a spacing device).
      • Give prednisolone 30 mg orally (if available).
      • Repeat the bronchodilator treatment as necessary.
      • For further information, see the CKS topic on Asthma.
    • Acute exacerbation of chronic obstructive pulmonary disease.
      • Give a bronchodilator (for example nebulized salbutamol 5 mg, or repeated doses of a metered-dose inhaler via a spacing device).
      • Give prednisolone 30 mg orally (if available).
      • Repeat the bronchodilator treatment as necessary.
      • For further information, see the CKS topic on Chronic obstructive pulmonary disease.
    • Tension pneumothorax: if the diagnosis is certain, and the person's condition is life threatening, consider inserting a large bore cannula through the second intercostal space in the mid-clavicular line, on the side of the pneumothorax.

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