Emergency!
In the final part of our series David Howell, Richard Marshall, Hugh Montgomery, and
Neil Goldsack explain how to manage elderly breathless patients
A breathless elderly patient will
undoubtedly be one of the commonest emergencies that you are
called to as a house officer. The aetiology
behind this presentation is often diverse.
One of the big problems with treating
elderly breathless patients is that they often
display multiple pathologies. Therefore, if
you are called to see an elderly patient who
is breathless and has multiple pathologies
the same principles outlined in all the previous articles apply.
(1) Tell the nurse to sit the patient up,
check O2 saturations, and expect you at the
patient's side immediately.
(2) Immediate assessment. Check the
adequacy of the Airway, Breathing and
Circulation (ABC). So check oxygen saturation and then give the patient oxygen
(provided the patient is not known to have
chronic obstructive airways disease, in
which case start off with 2 litres/minute or
28% through a ventimask and titrate
according to arterial blood gas analysis-see
below). If the oxygen saturation is less than
90% call for senior help immediately.
(3) Call for help if necessary. Breathless
patients can be very frightening. If you are
at all concerned, summon specialist help.
(4) Briefly assess the patient. Your initial
assessment should comprise taking the
patient's pulse and blood pressure. If the
patient has low blood pressure, call immediate help.
(5) Start emergency treatment. With
elderly patients, it is often useful to start
treatment while the initial assessments are
taking place. If a patient is known to have
either congestive cardiac failure or chronic obstructive airways disease then start giving a salbutamol (2.5-5mg) nebuliser and
give 40 mg of intravenous frusemide
(furosemide) as soon as you have obtained
venous access.
(6) Arrange simple urgent investigations: electrocardiogram, chest x radiography with a portable machine, full blood
count, urea and electrolytes, glucose, cardiac enzymes, and arterial blood gases.
(7) Treat the cause of the breathlessness.
Armed with these simple results and a
brief examination you should now be able
to start the appropriate treatment (see
below).
(8) "Not for CPR." This issue can be very
important in the early stages of managing
an acutely breathless, elderly patient.
Decisions such as these are not the house
officer's responsibility. With any unwell
patient, involve your seniors immediately
and never be pressurised into making a
decision about a patient's resuscitation
status on your own. If there is any doubt,
or if there is a delay in the arrival of your
senior colleagues, then all patients are for
full active treatment.
Common causes of acute breathlessness in elderly patients
Chronic obstructive airways disease
This is extremely common in those
elderly people who have smoked or continue to smoke. The diagnosis of chronic
obstructive airways disease is a clinical
one, but it includes those patients who
have chronic bronchitis and emphysema,
and there is often a mixture of both. It is
crucial to get an accurate history in these
patients. Classically, the patient presents
acutely breathless with a fever, with associated increasing cough and production
of sputum, which may have been preceded by an infection of the upper respiratory tract. The patient also may already be
having domiciliary treatment with oxygen.
The physical examination is useful as
patients with chronic obstructive airways
disease often have classic signs. Visually,
patients may be very distressed, with an
audible wheeze and a barrel chest resulting from hyperinflation. Exhalation often
occurs through pursed lips and patients
use their accessory muscles of respiration.
The chest examination itself may reveal
widespread polyphonic wheezes or coarse
crepitations, or both, and a dull percussion note over the relevant area with
bronchial breathing, if there is an associated pneumonia. Patients will often be
tachycardic and even shocked. The pulse
may also give you crucial evidence of carbon dioxide retention (hypercapnia).
Hypercapnia causes vasodilatation of the
vasculature which manifests as warm,
flushed skin and a strong, bounding
peripheral pulse. Other signs associated
with hypercapnia are a respiratory "flap"
at the wrist, and even coma if the hypercapnia is very severe. In addition, in the
setting of cor pulmonale (right ventricular failure), the neck veins may be distended, the liver may be enlarged, and
widespread peripheral oedema and
ascites may be present.
These patients should be managed as
outlined above. The initial assessment
should include Airway, Breathing,
Circulation (ABC).
If a patient is shocked or in extremis,
seek urgent senior help as s/he may need
to be rapidly intubated. If this is not the
case ensure there is intravenous access,
position a pulse oximeter, and start careful oxygen treatment (see below). Ensure
that an electrocardiogram is taken and
chest x radiography organised. It is also
important to analyse arterial blood gases
as early as possible, especially if hypercapnia is suspected. In addition, make
sure you take routine venous bloods,
blood cultures, and atypical serology if
you suspect that the patient has pneumonia.
Oxygen treatment
Patients with chronic obstructive airways
disease who present with hypoxia fall
broadly into two groups: those who are
hypoxic with a low arterial oyygen tension
(pO2) and normal arterial carbon dioxide
tension (pCO2), who have type I respiratory failure; and those who have a low pO2
with a high pCO2, which is type II respiratory failure. One of the most crucial factors
that you must establish early in these
patients with chronic obstructive airways
disease is what type of respiratory failure
they have. Patients with type II respiratory failure can be exceptionally sensitive to
oxygen treatment, and overzealous use can
lead to loss of a patient's hypoxic drive and
a catastrophic rise in pCO2. Do not be
fooled by the oxygen saturation on a pulse
oximeter. You may be delivering 15 litres
of oxygen per minute, watching the oxygen saturations rise, and be satisfied so as
not to bother to check the arterial oxygen
content (pO2) on a blood gas. After abolition of the patient's hypoxic drive, however, his/her pCO2 may be also begin to rise
and CO2 narcosis can develop, usually
within about 15 minutes.
If you see patients with presumed
chronic obstructive airways disease, always
treat the hypoxia. The hypoxia will kill
them before the hypercapnia does. You
should therefore always treat these
patients with oxygen as a life saving measure. Use controlled oxygen given via a
ventimask, however, through which you
know the delivered inspired oxygen concentration, and check the blood gases regularly to see if the patient is retaining carbon dioxide. The subsequent titration of
arterial blood gases against the percentage of inspired oxygen should be done by
a senior colleague. You will then see if the
pCO2 is rising and, subsequently, the
blood pH falling, so that other interventions may be required. In these instances,
if you cannot maintain an acceptable concentration of pO2 without a significant rise
in pCO2, the patient may need to be ventilated or receive respiratory support with
non-invasive ventilatory strategies. This
needs to be discussed urgently with other
senior colleagues
The drug treatment of this disease has
been helped by published guidelines.1
Depending on the severity, chronic
obstructive airways disease can be treated
with a range of bronchodilators. Nebulised
salbutamol (2.5-5mg) is useful.
The patient may also benefit from the
addition of aminophylline or the respiratory stimulant doxapram, especially if
hypercapnia is present (these are decisions
for a senior colleague).
Some patients with chronic obstructive
airways disease respond to steroids, and
these should be given as early as possible if
this is the case. Even if you do not know
whether the patient will respond, it is generally sensible to give steroids anyway until
the full history is known.
Many will have coexistent chest infections
that will require broad spectrum antibiotics.
As mentioned, if the patient is severely
unwell, she may require ventilation.
The recent introduction of non-invasive
ventilatory strategies has revolutionised the
treatment of type II respiratory failure, and
these are becoming more available in all
hospitals.
Heart failure
This condition can present very acutely, as
devastating left ventricular failure, or
chronically, as congestive cardiac failure.
In elderly people the commonest aetiology of both of these conditions is ischaemic
heart disease. Patients may present with
acute myocardial infarction impairing
blood flow to the left ventricle. If the left
ventricle can no longer pump efficiently,
pulmonary oedema develops. Congestive
cardiac failure tends to present more insidiously, with worsening breathlessness often
exacerbated by a intercurrent condition.
The history is again crucial in these
patients. They may have had a long history of ischaemic heart disease or be lifelong
smokers. A history of diabetes, hypertension, or hypercholesterolaemia, or a positive family history, may also be found. Do
not forget that diabetic patients can present with silent ischaemia or infarcts that
do not cause classic chest pain.
On examination, patients may look terrified and be profoundly sweaty, cold,
clammy, and cyanosed. They may have
audible cardiac wheeze and the chest will
have widespread coarse crepitations
throughout. In contrast to the chronic
obstructive airways disease patient, the
pulse will be thready and of poor volume
and may demonstrate pulsus alternans
due to variable volume of the pulse. The
patients may have pre-existing or new
atrial fibrillation. This rhythm decreases
the cardiac output of the heart by up to
30% and is a common reason for patients
to develop left ventricular failure. They
will also be cold at the peripheries rather
than warm and vasodilated. Examination
of the heart can actually be quite difficult
if the crepitations in the chest are very
loud but will reveal a tachycardia. If the
onset is more insidous, and the patient
has congestive cardiac failure, she may be
less breathless but also have other signs of
salt and water retention such as a raised
jugular venous pressure, hepatolmegaly,
ascites and gross peripheral oedema.
The treatment of acute left ventricular
failure relies on the principle of reducing
the afterload and increasing the pumping
function of the myocardium. As always,
seek senior help immediately if the patient
is seriously unwell.
Reassure the patient and sit him/her bolt
upright and give high flow oxygen.
Position a pulse oximeter and a cardiac
monitor on the patient, obtain venous
access, take routine bloods including a creatine kinase and get an urgent electrocardiogram. The immediate underlying
cause may be apparent. If the patient has
had a myocardial infarction, specific treatment may be needed urgently.
However, drugs which are very useful to
specifically treat the left ventricular failure
are diamorphine (2.5mg), frusemide
(40mg) and glyceryl trinitrate (2 puffs
under the tongue followed by an intravenous infusion 1-4mg/hour). Contrary to
popular belief, frusemide does not cause
reduction in pulmonary oedema by
making patients have a diuresis. It is
thought that these drugs cause venodilatation of large central capacitance vessels
which allows fluid to leave the lung interstitium. If patients fail to respond, they may
need ionotropic support for their pump
failure-a decision for your seniors.
Typical appearance of left venticular failure
Asthma
Asthma is common in elderly patients.
Always consider it. The principles for treating it have been described in a previous
article.2
It is, however, important to remember that even though it is still possible for
elderly people to present with new onset
asthma many may have had it for years.
Patients with chronic asthma can develop
relatively fixed airways obstruction owing
to remodelling of their airways. They are
more problematic as the wheeze may not
respond to conventional treatment.
Pneumonia
Elderly patients are at increased risk of
pneumonia. The usual pathogens seen in
younger patients abound, including
Streptococcus pneumonia and the atypicals
(mycoplasma and legionella). Patients with
chronic obstructive airways disease have
an increased risk of haemophilus infection
and are also more susceptible to other
causes of pneumonia including
Staphylococcus aureus (especially in times of
influenza epidemics) and klebsiella.
Typical appearance of right lobar pneumonia
Pulmonary emboli
Pulmonary vascular disease is also common in the elderly. The catastrophic
problem is obviously pulmonary embolus,
which can present as sudden onset breathlessness and shock. However, smaller or
recurrent emboli can cause more insidious
breathlessness, and a careful history and
examination looking for deep vein thromboses, atrial fibrillation, and valvular
abnormalities are crucial. The investigation and clinical presentation of this con-
dition have been previously dealt with.3
Pulmonary fibrosis
Another condition which is commoner in
the elderly is pulmonary fibrosis. This can
be very confusing as the patients will have
fine crepitations at their lung bases which
are often confused with pulmonary oedema. A careful history and examination will
help you distinguish between these cases.
Lung cancer
Lung carcinoma is common in the elderly and can present in many forms. It may
present with actual breathlessness due to
a sudden collapse of a lung or with a slower onset due to a malignant pleural effusion. The signs of a large pleural effusion
are tracheal deviation away from the effusion with stony dullness on percussion and
reduced breath sounds.
Hyperventilation
It is crucial to remember that the body will
resist any metabolic acidosis by compensating with a respiratory alkalosis. The
body does this by increasing the respiratory rate, and blowing off more carbon
dioxide. This essentially means you can
have a very breathless patient without any
cardiac or chest pathology at all. We have
touched on causes of acidosis before but
remember that the shocked patient from
whatever cause will become acidic. Other
causes such as diabetic ketoacidosis, hyperosmolar non-ketotic acidosis, and renal
failure are common in the elderly and
must always be thought of. In addition,
poisoning from drug overdoses such as
salicylate (aspirin) is still common in the
elderly, whether it be an act of deliberate
self-harm or not. Salicylate poisoning can
cause enormous changes in acid-base balance and subsequent respiratory compensation. Psychogenic hyperventilation can
be difficult to manage, but always take a
full history and be guided by the investigations you perform.
Others
The elderly can still present with pneumothoraces although they are commoner
when complicating chronic obstructive airways disease. Inhalation of foreign bodies
is another cause of breathlessness in this
group, particularly if bulbar problems due
to associated cerebrovascular insufficiency
is coexistent. Finally, remember that the
elderly can suffer from anaphylaxis, just as
the young, which we discussed in a previous article.
Conclusion
This final article in the series, like the others, is based on simple principles that
should make your house officer life much
easier. We do hope that you have found
the series useful and that it will turn you all
into more confident doctors.
David Howell, Medical Research Council respiratory specialist registrar
Richard Marshall, Wellcome respiratory specialist registrar
Hugh Montgomery, cardiology specialist registrar, University College and Middlesex Hospitals, London
Neil Goldsack, Wrespiratory specialist registrar, Royal Free Hospital, London
studentBMJ 2000;08:1-44 February ISSN 0966-6494
- BTS guidelines for the management of chronic obstructive pulmonary disease. The COPD
Guidelines Group of the Standards of Care Committee of the BTS. Thorax 1997;52:Suppl 5:S128.
- Goldsack N, Montgomery H, Marshall R, Howell D. Management of young breathless patients.
- studentBMJ 1999;7:96-8. (April.)
Ghandi S, Marshall R, Montgomery H, Howell D, Goldsack N. Bedside monitoring. studentBMJ
1999;7:450-1. (December.)
