Breathlessness and presentation to the emergency department : a survey and clinical record review

BACKGROUND: Breathlessness is a frequently occurring symptom of cardiorespiratory conditions and is a common cause of emergency department presentation. The aim of this study was to estimate the prevalence of acute-on-chronic breathlessness as a cause for presentation to the major emergencies area of the emergency department. METHODS: A prospective patient self-report survey and clinical record review of consecutive attendees to the major emergencies area of the emergency department in a single tertiary hospital between 12/5/14 and 29/5/14 was conducted. Eligible patients were clinically stable and had mental capacity to provide data. RESULTS: There were 2,041 presentations during the study period, of whom 1,345 (66%) were eligible. There was a 90% survey response rate (1,212/1,345); 424/1,212 (35%) self-reported breathlessness most days over the past month of whom 245 gave breathlessness as a reason for this presentation. Therefore, the prevalence of acute-on-chronic breathlessness as a reason to present to the major emergencies area was 20.2% (245/1,212, 95% CI 17.9% to 22.5%). During this period there were 4,692 major and minor presentations; breathlessness was therefore a cause of at least 5.2% (245/4,692, 95% CI 4.6 to 5.9%) of all emergency department presentations. CONCLUSIONS: This study found that one in five ambulance presentations to the ED were due to acute-on-chronic breathlessness. Most patients had non-malignant underlying conditions, had experienced considerable breathlessness for an extended period, had discussed breathlessness with their GP and presented out of daytime hours. Others were often involved in their decision to present. This represents clinically significant burden for patients, their family carers and the emergency health services

No room to breathe: the importance of lung hyperinflation in COPD

Patients with chronic obstructive pulmonary disease (COPD) are progressively limited in their ability to undertake normal everyday activities by a combination of exertional dyspnoea and peripheral muscle weakness. COPD is characterised by expiratory flow limitation, resulting in air trapping and lung hyperinflation. Hyperinflation increases acutely under conditions such as exercise or exacerbations, with an accompanying sharp increase in the intensity of dyspnoea to distressing and intolerable levels. Air trapping, causing increased lung hyperinflation, can be present even in milder COPD during everyday activities. The resulting activity-related dyspnoea leads to a vicious spiral of activity avoidance, physical deconditioning, and reduced quality of life, and has implications for the early development of comorbidities such as cardiovascular disease. Various strategies exist to reduce hyperinflation, notably long-acting bronchodilator treatment (via reduction in flow limitation and improved lung emptying) and an exercise programme (via decreased respiratory rate, reducing ventilatory demand), or their combination. Optimal bronchodilation can reduce exertional dyspnoea and increase a patient’s ability to exercise, and improves the chance of successful outcome of a pulmonary rehabilitation programme. There should be a lower threshold for initiating treatments appropriate to the stage of the disease, such as long-acting bronchodilators and an exercise programme for patients with mild-to-moderate disease who experience persistent dyspnoea