Case Study : Respiratory

167. Pulmonary Embolism

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Breathlessness with a cough

Presentation : A 35-year-old woman presents 5 days after returning from holiday describing a feeling of needing to use extra effort to breathe, together with a cough.

Her notes showed that she had a chest infection 2 years previously.

Examination reveals that she is overweight, has a regular pulse of 96 bpm, and normal heart sounds with normal pulse oximetry (95%).

Chest auscultation is normal with a respiratory rate of 18 breaths/min and there are no signs of swelling in either leg.

 

The IMPRESS algorithm is designed to assist clinicians during the initial assessment of a patient presenting with acute or chronic breathlessness and is intentionally broad-based because of the large number of possible diagnoses.(1) 

These algorithms reflect that a patient may well have more than one condition contributing to the symptom of breathlessness and the existence of terms such as ‘cardiac asthma’ demonstrates that it is very easy to be led astray by symptoms more typical of other causes.

Important aspects of a clinical assessment of breathlessness

 

Diagnosis

While this patient initially thought that she might have another lung infection, the assessing doctor had suspicions of thromboembolic disease, so referred her to the medical on-call team who confirmed that she had a pulmonary embolism (PE).

 

Both conditions can cause breathlessness, tachypnoea, and tachycardia, but the absence of any other signs of infection and the presence of risk factors for PE should warrant appropriate consideration and further assessment.

Patients with PE do not always have signs of deep vein thrombosis (DVT).(2)

Management

The two-level PE Wells score can be utilised to estimate the clinical probability of PE.

 

Clinical features, and the associated point scores, are listed below: (3) (4)

  • clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) [3 points]

 

  • an alternative diagnosis is less likely than PE [3 points]

 

  • heart rate >100 beats per minute [1.5 points]

 

  • immobilisation for more than 3 days or surgery in the previous 4 weeks [1.5 points]

 

  • previous DVT/PE [1.5 points]

 

  • haemoptysis [1 point]

 

  • malignancy (on treatment, treated in the last 6 months, or palliative) [1 point].

 

A score of >4 points suggests that PE is likely, while a score of ≤4 points suggests that PE is unlikely.

Any patient for whom a diagnosis of PE is likely should be referred for hospital admission.(4) 

If there will be a delay, the clinician should consider interim treatment with low-molecular weight heparin prior to transfer.

This is in line with the recommendations in NICE Clinical Guideline 144 that patients in whom a PE is suspected should be offered either an immediate computed tomography pulmonary angiogram (CTPA) or immediate interim parenteral anticoagulant therapy followed by a CTPA, if a CTPA cannot be carried out immediately.(4)

Clinical outcome

The medical on-call team arranged a CTPA, which confirmed clots in the anterior segmental arteries of both lungs.

 

The patient was commenced on anticoagulation treatment as an inpatient and discharged to community follow up.

 

The patient attributed the full resolution of her symptoms to the prompt referral and treatment process.

 
 
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1. Acute breathlessness assessment

Improving and Integrating Respiratory Services in the NHS (IMPRESS).

The Health Foundation,

2014

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2. .History and physical examination in acute pulmonary embolism in patients without pre-existing cardiac or pulmonary disease.

Stein P, Willis P, DeMets D et al.

Am J Cardiol 1981; 47 (2): 218–223

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3. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer.

Wells P, Anderson D, Rodger M et al.

Ann Intern Med 2001; 135 (2): 98–107.

Access

4. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing.

NICE Clinical Guideline CG144.

Published date: June 2012

Last updated: November 2015 

Access

Breathlessness: what's the diagnosis?

Dr Chris Cooper

Guidelines in practice

October 2017

Access

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