Understanding breathlessness in patients
Shortness of breath, or dyspnoea, is a common symptom in emergency department patients.
With no ‘gold standard’ for diagnosing the cause of breathlessness and numerous illnesses sharing this key symptom, discovering the underlying cause is not always straightforward.
A recent Asian-Pacific study, which was co-funded by the Emergency Medicine Foundation (EMF), has provided clinicians with an important insight into the causes and diagnosis of breathlessness.
The Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study recruited 3044 patients with shortness of breath from 46 emergency departments in Australia, New Zealand, Singapore, Hong Kong and Malaysia.
Professor Gerben Keijzers, a Senior Staff Specialist at the Gold Coast University Hospital Emergency Department and a co-investigator on the study, said AANZDEM had generated a lot of excitement.
“This is the first time data has been collected on this scale on patients presenting to the emergency department with breathlessness,” Professor Keijzers said.
“The findings really highlighted that in the emergency department we deal with undifferentiated patients and we don’t know what’s going on with them. We have to be pragmatic and consider multiple options.”
The team found that nearly half (47%) of breathlessness cases were respiratory related, ranging from chest infections (20%) and asthma (13%) to lung disease (14%). However, heart failure was the second most common cause (15%) of breathlessness.
There was also a subgroup of patients who had both lung and heart problems.
When the researchers looked further at patients with heart failure, they found that most had previously suffered a heart attack and the majority were over 60 years of age with an even gender distribution. In total, 86 per cent of patients were admitted to hospital, with the emergency department diagnosis of heart failure correct in 81 per cent of cases.
“Overall, even without standard clinical guidelines, emergency doctors have been doing a good job of diagnosing heart failure in patients with breathlessness, which demonstrates the value of clinical judgement,” Professor Keijzers said.
“What we have shown is that emergency doctors need to be aware that women with breathlessness may be experiencing heart failure. Traditionally, heart disease was thought to be a male dominated condition, but females with breathlessness are at just as high risk.”
The AANZDEM study looks likely to lead to further research in this area, and potentially the development of clinical guidelines for diagnosing breathlessness, which include additional recommendations for emergency department patients.
The study has led to four journal publications between 2016 and 2017, with several more in press. It was led by Professor Anne-Maree Kelly, a senior emergency physician at Western Health in Victoria and Director of the Joseph Epstein Centre for Emergency Medicine Research.
The EMF grant for this project was funded by Queensland Health.
The grant enabled 11 Queensland hospitals to take part in the study, including the Gold Coast University Hospital, The Prince Charles Hospital, Redlands Hospital, Redcliffe Hospital, Cairns Hospital, QEII Jubilee Hospital, Ipswich Hospital, Princess Alexandra Hospital, Nambour Hospital, The Townsville Hospital and Greenslopes Hospital.
In the study, patients with shortness of breath made up 5 per cent of emergency department presentations, 11 per cent of ward admissions and 20 per cent of intensive care unit (ICU) admissions. Of the patients presenting to the emergency department, 64 per cent were admitted to hospital with 3 per cent requiring ICU admission.
Journal publications
- Laribi S., Keijzers G., van Meer O., Klim S., Motiejunaite J., Kuan W.S., Body R., Jones P., Karamercan M., Craig S., Harjola V.P., Holdgate A., Golea A., Graham C., Verschuren F., Capsec J., Christ M., Grammatico-Guillon L., Barletta C., Garcia-Castrillo .L, Kelly A.M.; AANZDEM and EURODEM study groups, ‘Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region’, Eur J Emerg Med. 2018 Aug 30. doi: 10.1097/MEJ.0000000000000571. [Epub ahead of print]
- Kuan WS, Craig S, Kelly AM, Keijzers G, Klim S, Graham CA, Jones P, Holdgate A, Lawoko C, Laribi S., ‘Asthma among adult patients presenting with dyspnea to the emergency department: An observational study’, Clin Respir J., 2018 Jun;12(6):2117-2125. doi: 10.1111/crj.12782. Epub 2018 Mar 24.
- Kelly AM, Holdgate A, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Lawoko C, Laribi S., ‘Epidemiology, treatment, disposition and outcome of patients with acute exacerbation of COPD presenting to emergency departments in Australia and South East Asia: An AANZDEM study, Respirology, 2018 Jul;23(7):681-686. doi: 10.1111/resp.13259. Epub 2018 Feb 2.
- Keijzers G, Kelly AM, Cullen L, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Holdgate A, Lawoko C, Laribi S., ‘Heart failure in patients presenting with dyspnoea to the emergency department in the Asia Pacific region: an observational study’, BMJ Open, 2017 Feb 28;7(2):e013812. doi: 10.1136/bmjopen-2016-013812.
- Kelly AM, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Holdgate A, Lawoko C, Laribi S; AANZDEM Study Group, ‘An Observational Study of Dyspnea in Emergency Departments: The Asia, Australia, and New Zealand Dyspnea in Emergency Departments Study (AANZDEM)’, Acad Emerg Med., 2017 Mar; 24(3):328-336. doi: 10.1111/acem.13118.
- Kelly AM, Holdgate A, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Lawoko C, Laribi S; AANZDEM study group, ‘Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: an observational study.’, Scand J Trauma Resusc Emerg Med. 2016 Sep 22;24(1):113.
- Kelly AM, Keijzers G, Klim S, Graham CA, Craig S, Kuan WS, Jones P, Holdgate A, Lawoko C, Laribi S; AANZDEM Study Group, ‘Asia, Australia and New Zealand Dyspnoea in Emergency Departments (AANZDEM) study: Rationale, design and analysis.’, Emerg Med Australas, 2015 Jun;27(3):187-91. doi: 10.1111/1742-6723.12397. Epub 2015 May 4.
- Photo: Professor Gerben Keijzers courtesy of Gold Coast Health.
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