Breathlessness of with exertion

Case Study : Respiratory

165. Acute exacerbation of COPD

Breathlessness with exertion

Presentation : A 66-year-old woman visits the practice complaining of increasing phlegm production with breathlessness, worsening over the past 3 days.

She normally only gets breathless if walking uphill, but is now breathless walking on level ground.

She managed to quit smoking 2 years ago after previously smoking 10 cigarettes per day for over 50 years.

On auscultation there is reduced air entry throughout the chest with a few scattered crackles

Presentation

Important aspects of a clinical assessment of breathlessness

Diagnosis

Management

Clinical outcome

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

This patient has an infective exacerbation of COPD and there is no clinical suggestion of pneumonia.

If basic observations, including pulse and oxygen saturations, are within the normal range it is appropriate to treat the patient in the community.

If the patient has had repeat exacerbations, it would be worth ensuring there is no suggestion of malignancy, using a chest X-ray in the first instance.

Go To : COAD exacerbation prescribing (169)

Management

In addition to maximising inhaled short-acting bronchodilators (beta2 -agonists, with or without anticholinergics) for this moderate exacerbation of COPD, prescription of a 5–7 day course of both prednisolone 40 mg and an appropriate antibiotic is warranted.(2)

Interval follow up is important to ensure the patient returns to their usual level of symptoms and allows for assessment of other contributory conditions, such as heart failure, if the patient does not recover to their usual level of function.

Promotion of the influenza vaccine early in the season can help to prevent winter exacerbations and reduce hospital admissions.(3)

Pulmonary rehabilitation: (4)

should be made available to people with COPD where appropriate, including those who have had a recent hospitalisation for an acute exacerbation

should be offered to all patients who consider themselves functionally disabled by COPD (usually modified Medical Research Council [mMRC] scale grade 3 and above)