Breathlessness
Breathlessness - Summary
Breathlessness is the distressing sensation of a deficit between the body's demand for breathing and the ability of the respiratory system to satisfy that demand.
Breathlessness can be classified by its speed of onset as:
Acute breathlessness — when it develops over minutes, hours, or days.
Chronic breathlessness — when it develops over weeks or months.
Common cardiac causes of breathlessness include:
Silent myocardial infarction.
Cardiac arrhythmia.
Acute pulmonary oedema.
Chronic heart failure.
Common pulmonary causes of breathlessness include:
Asthma.
Chronic obstructive pulmonary disease (COPD).
Pneumonia.
Pulmonary embolism.
Other common causes of breathlessness include:
Anaemia.
Diaphragmatic splinting (due to obesity or pregnancy).
Psychogenic breathlessness.
The management of breathlessness includes determining the need for emergency admission by assessing the person's blood pressure, pulse, temperature, level of consciousness, peak expiratory flow rate (PEFR), oxygen saturation, and (if possible) electrocardiogram (ECG).
Emergency admission should be arranged for people with:
Respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
Peak expiratory flow rate (PEFR) less than 33% of predicted.
Altered level of consciousness.
A large respiratory effort (particularly if the person is becoming exhausted).
Stridor.
Clinical features of a pulmonary embolus or pneumothorax.
ECG suggesting a cardiac arrhythmia or myocardial infarction.
Emergency admission should be considered, depending on the severity and number of risk factors present and if the person has breathlessness associated with any of the following:
Elevated respiratory rate (but if it is more than 30 breaths per minute, emergency admission should be arranged).
Tachycardia (but if it is more than 130 beats per minute, emergency admission should be arranged).
Hypotension (but if blood pressure is less than 90 mmHg systolic or 60 mmHg diastolic, emergency admission should be arranged).
A high temperature (particularly if higher than 38.5°C).
PEFR less than 50% of predicted (but if it is less than 33%, emergency admission should be arranged).
Older than 65 years of age.
If emergency admission is indicated and the person has an oxygen saturation of less than 92%, oxygen should be given and oxygen saturation levels continuously monitored while awaiting transfer to hospital.
For chronic breathlessness, emergency admission is most commonly required when a new acute problem (such as a respiratory tract infection, pulmonary embolism, or sudden-onset arrhythmia) exacerbates breathlessness caused by a chronic condition (such as COPD or chronic heart failure).
If emergency admission is not indicated, the underlying cause of breathlessness should be managed and investigations arranged to identify or confirm the underlying cause of breathlessness.
Have I got the right topic?
This CKS topic covers the management of adults presenting with breathlessness (acute or chronic) in primary care. It includes recommendations on who should be admitted as an emergency, interim treatment if emergency admission is required, and investigations to determine the underlying cause if admission is not required.
This CKS topic does not cover the long-term management of the underlying causes of breathlessness.
There are separate CKS topics on Asthma, Bronchiectasis, Chest infections - adult, Chronic obstructive pulmonary disease, Heart failure - chronic, Lung cancer - suspected, and Palpitations.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
April to August 2010 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 March 2010.
HTAs (Health Technology Assessments)
No new HTAs since 1 March 2010.
Economic appraisals
No new economic appraisals relevant to England since 1 March 2010.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Bailey, C.D., Wagland, R., Dabbour, R., et al. (2010) An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses. BMC Pulmonary Medicine 10, 63. [Abstract] [Free Full-text]
Primary evidence
No new randomized controlled trials published in the major journals since 1 March 2010.
New policies
No new national policies or guidelines since 1 March 2010.
New safety alerts
No new safety alerts since 1 March 2010.
Changes in product availability
No changes in product availability since 1 March 2010.
Goals and outcome measures
Goals
To support primary healthcare professionals:
To decide whether emergency admission is required
To determine the underlying cause of the breathlessness
To appropriately refer the person for further investigation and treatment
Background information
Definition
What is it?
Breathlessness is the distressing sensation of a deficit between the body's demand for breathing and the ability of the respiratory system to satisfy that demand.
Breathlessness can be classified by its speed of onset as:
Acute breathlessness — when it develops over minutes, hours, or days.
Chronic breathlessness — when it develops over weeks or months.
Causes
What causes it?
Acute breathlessness most commonly has a pulmonary or cardiac cause.
Pulmonary causes include:
Acute asthma.
Acute exacerbation of chronic obstructive pulmonary disease.
Pneumonia.
Pulmonary embolism.
Pneumothorax.
Pleural effusion.
Acute exacerbation of bronchiectasis.
Lung or lobar collapse (caused by bronchial obstruction, or compression by cancer, an inhaled foreign body, or retained secretions).
Upper airway obstruction (for example by a foreign body or acute epiglottitis) causing stridor.
Cardiac causes include pulmonary oedema secondary to:
Acute deterioration of chronic heart failure.
Sudden-onset cardiac arrhythmia (for example supraventricular tachycardia).
Ischaemic heart disease (including an atypical presentation of myocardial infarction).
Acute valvular dysfunction.
Cardiac tamponade.
Other causes include:
Metabolic causes (including aspirin overdose, diabetic ketoacidosis, and renal failure).
Acute blood loss.
Psychogenic causes (including anxiety disorders, especially panic disorders).
Chronic breathlessness most commonly has a pulmonary or cardiac cause.
Pulmonary causes include:
Chronic obstructive pulmonary disease, asthma, and bronchiectasis.
Interstitial lung disease (including asbestosis, idiopathic pulmonary fibrosis).
Recurrent pulmonary embolism.
Pleural effusion.
Pleural infiltration by mesothelioma.
Cardiac causes include chronic heart failure caused by:
Hypertension.
Ischaemic heart disease.
Cardiomyopathy.
Valvular heart disease.
Cardiac arrhythmia.
Other causes include:
Anaemia.
Metabolic causes (including aspirin overdose, diabetic ketoacidosis, and renal failure).
Thyroid disease.
Diaphragmatic splinting (due to obesity, pregnancy, or ascites).
Hypoventilation (caused by neuromuscular conditions such as Guillain–Barré syndrome or motor neurone disease).
Causes and clinical features
Causes of breathlessness and their clinical features
Cardiac causes
What are the clinical features of the common cardiac causes of breathlessness?
Silent myocardial infarction
Risk factors — smoking, high blood lipid levels, hypertension, obesity, diabetes, family history.
Symptoms — breathlessness, general malaise, sudden collapse, upper body discomfort.
Signs — breathless (sometimes), abnormal pulse rate, sweating, reduced peripheral perfusion.
Electrocardiogram (ECG) — features suggestive of acute MI include ST depression with T-wave inversion, persistent ST elevation, or new left bundle branch block. Q-waves are characteristic of a resolved MI.
Cardiac arrhythmia
Risk factors — heart failure, valvular heart disease, ischaemic heart disease.
Symptoms — palpitations, breathlessness, chest pain, syncope (or near syncope).
Signs — bradycardia or tachycardia.
ECG — changes that are evident when the person is symptomatic are diagnostic. Typical ECG features of supraventricular tachycardia (SVT) that are treatable in primary care include:
P-waves (usually not identifiable), regular narrow QRS complex tachycardia (unless the person has a bundle branch block as well), and a rate that is usually 130–250 bpm.
For an image of a typical SVT trace, see Wikimedia Commons.
Acute pulmonary oedema
Risk factors — chronic heart failure, ischaemic heart disease, valvular heart disease.
Symptoms — severe breathlessness, orthopnea, coughing (rarely frothy blood-stained sputum).
Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (occasionally) wheeze. Peripheral circulation is shut down (in contrast to people with an acute exacerbation of chronic obstructive pulmonary disease).
Chronic heart failure
Risk factors — hypertension, ischaemic heart disease, valvular heart disease, chronic cardiac arrhythmia.
Symptoms — fatigue and breathlessness, including orthopnea and paroxysmal nocturnal dyspnoea.
Signs — basal crackles, displaced apex beat, third heart sound, and (if congestive cardiac failure is present) increased jugular venous pressure, dependent oedema, and hepatomegaly.
Basis for recommendation
Basis for recommendation
Clinical features of silent myocardial infarction
These are based on evidence, from observational studies, that is summarized in an expert review of the clinical features of people with confirmed myocardial infarction presenting without chest pain [Wong and White, 2002].
Clinical features of cardiac arrhythmia
These are based on expert observation reported in the Oxford textbook of medicine [Cobbe et al, 2010].
The ECG features of SVT are based on expert observation reported in The ECG in practice [Hampton, 2008].
Clinical features of pulmonary oedema
These are based on expert observation reported in the Oxford textbook of medicine [Morrell and Firth, 2010].
Clinical features of chronic heart failure
These are based on expert observation reported in guidelines issued by National Collaborating Centre for Chronic Conditions, the Scottish Intercollegiate Guidelines Network, and the European Society of Cardiology [National Collaborating Centre for Chronic Conditions, 2003; SIGN, 2007; European Society of Cardiology, 2008].
Pulmonary causes
What are the clinical features of the common pulmonary causes of breathlessness?
Asthma
Risk factors — personal history of rhinitis or eczema, or family history of atopy.
Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.
Peak expiratory flow rate (PEFR) is reduced during an acute episode. Acute asthma is:
Life-threatening — when PEFR is less than 33% of predicted, and is associated with tachycardia, hypotension, a silent chest, or impaired level of consciousness.
Severe — when PEFR is 33–50% of predicted, and is associated with a respiratory rate of more than 25 breaths per minute and an inability to complete full sentences.
Moderate — when PEFR is more than 50% of predicted, with a respiratory rate of less than 25 breaths per minute.
Chronic obstructive pulmonary disease
History — typically, the person is older than 35 years of age, is a smoker (or past smoker), and reports slowly progressive breathlessness.
Symptoms — persistent progressive breathlessness that is often associated with wheezing or chest tightness, and a cough (producing purulent sputum). Acute exacerbations of symptoms are common, and are frequently caused by respiratory tract infection.
Signs — wheeze, hyperinflated chest (in emphysema), crackles (when infection is present). There may be signs of right-side heart failure in people with severe disease, including swollen ankles and increased jugular venous pressure. The person's peripheries (the hands and feet) are often warm to the touch and a dusky colour (cyanosed), with distended veins.
Pneumonia
Symptoms — cough associated with at least one other symptom of breathlessness, sputum production, wheeze, or pleuritic pain.
Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus/resonance) plus at least one systemic feature (such as fever/sweating, myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion.
Pulmonary embolism (PE)
Risk factors — immobilization, surgery, cancer, symptoms or signs of deep vein thrombosis (DVT).
Symptoms — acute-onset breathlessness (in 73% of people with PE), pleuritic pain (66%), cough (37%), haemoptysis (13%). Recurrent acute episodes may lead to chronic breathlessness.
Signs — tachypnoea of more than 20 breaths per minute (in 70% of people with PE), crackles (51%), tachycardia (30%), signs of DVT (11%).
Pneumothorax/tension pneumothorax
Risk factors — smoking, age and body type (adults who are young, tall, and slim), previous pneumothorax, chronic respiratory disease (such as chronic obstructive pulmonary disease or asthma), trauma to chest wall (including therapeutic procedures such as injections and aspirations).
Symptoms — collapse, sudden-onset pleuritic pain, breathlessness.
Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in a rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
Pleural effusion
Causes — include: heart, liver, or renal failure; pneumonia; pulmonary embolism; cancer (including mesothelioma); tuberculosis; pleural infection (empyema); and autoimmune disease.
Symptoms — progressive breathlessness.
Signs — reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart or renal failure) signs of fluid overload.
Lung/lobar collapse
Causes — airway compression (for example by enlarged lymph nodes infiltrated with cancer) or blockage (secondary to pneumonia or an inhaled foreign body).
Symptoms — breathlessness, cough.
Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.
Bronchiectasis
History — suspect in people with a history of recurrent or chronic productive cough, especially if they do not smoke.
Symptoms — cough with daily sputum production (present in 75–100% of adults), progressive breathlessness (72–83%), haemoptysis (51–45%), non-pleuritic chest pain between exacerbations (31%).
Signs — coarse crackles during early inspiration that are heard in the affected areas, usually in the lower lung fields (70% of adults). Others include wheeze (34%) and large airway rhonci (44%). Finger clubbing occurs infrequently.
Interstitial lung disease (ILD)
Causes — include idiopathic pulmonary fibrosis, sarcoidosis, pneumoconioses, ILD associated with drug therapy, ILD associated with connective tissue disease, and hypersensitivity pneumonitis/extrinsic allergic alveolitis (following sensitization to inhaled environmental allergens; for example from birds, hay, or mushrooms).
Symptoms — cough and slowly progressive breathlessness. When it is caused by extrinsic allergic alveolitis there may be a history of recurrent episodes of flu-like illness following exposure to the responsible allergen. There may be symptoms of the underlying cause (for example joint pains when the ILD is associated with connective tissue disease).
Signs — there may be none in sarcoidosis. When present, there may be fine end-inspiratory crepitations (indicative of fibrosis), finger clubbing, cyanosis, and signs of right heart failure.
Basis for recommendation
Basis for recommendation
Clinical features of pulmonary embolism
These are based on evidence from a diagnostic study of the clinical features associated with confirmed pulmonary embolism [Stein et al, 1991].
Clinical features of pneumothorax
These are based on expert observation reported in the Oxford textbook of medicine [Davies et al, 2010].
Clinical features of tension pneumothorax
These are based on expert observation reported in the Oxford handbook of general practice [Simon et al, 2010].
Clinical features of asthma
These are based on expert observation, supported by observational studies reported in the British guideline on the management of asthma, issued by the British Thoracic Society and Scottish Intercollegiate Guidelines Network [SIGN and BTS, 2008].
Clinical features of chronic obstructive pulmonary disease
These are based on expert observation reported in the guideline Chronic obstructive pulmonary disease: national clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care [National Clinical Guideline Centre, 2010].
Clinical features of bronchiectasis
These are based on a summary of the evidence from observational studies, reported in the British thoracic society guideline for non-CF bronchiectasis [British Thoracic Society, 2010].
Diagnostic criteria for clinical features of community-acquired pneumonia
These are based on an assessment of the evidence on the sensitivity of clinical features to diagnose pneumonia, summarized in the British Thoracic Society guidelines on The management of community acquired pneumonia [British Thoracic Society, 2001; British Thoracic Society, 2009].
Clinical features of interstitial lung disease
These are based on expert observation reported in the Oxford textbook of medicine [Bradley et al, 2008; Baughman and Lower, 2010; Hendrick and Spickett, 2010; Seaton, 2010].
Clinical features of lung/lobar collapse
These are based on expert observation reported in the textbook Clinical medicine [Frew and Holgate, 2005].
Clinical features of pleural effusion
These are based on expert observation reported in the Oxford textbook of medicine [Davies et al, 2010].
Other common causes
What are the clinical features of the other common causes of breathlessness?
Anaemia
Symptoms — fainting, exertional breathlessness, fatigue, palpitations.
Signs — paleness (for example of the conjunctiva or palms).
Diaphragmatic splinting (due to ascites, obesity, or pregnancy)
Symptoms — chronic breathlessness that develops in association with increasing abdominal size. There are no symptoms to suggest other causes of chronic breathlessness.
Signs — ascites (shifting dullness and fluid thrill) or obesity. There are no clinical features of other causes for chronic breathlessness.
Psychogenic breathlessness
History — the person has no identifiable risk factors for a physical cause of breathlessness. Anxiety disorders are common, especially panic disorders. The episode is often preceded by a stressful event.
Symptoms — breathlessness is characteristically intense and may be associated with symptoms of hyperventilation (including tingling of the extremities, tetanus, and light-headiness). Other symptoms, such as palpitations and chest pain, may occur. Symptoms of anxiety may accompany breathlessness.
Signs — no signs of a physical cause for breathlessness. Breathing pattern may be irregular and gasping, and accompanied by sighing.
Basis for recommendation
Basis for recommendation
Clinical features of anaemia
These are based on expert observation reported in the Oxford textbook of medicine [Weatherall, 2010].
Clinical features of the causes of abdominal splinting
These are based on expert observation reported in Macleod's clinical examination [Ford et al, 2009].
Clinical features of psychogenic breathlessness
These are based on observational data from a Chinese study of 111 people with psychogenic breathlessness [Han et al, 2004].
Management
Management
Scenario : Acute breathlessness: covers the assessment and management of acute breathlessness. This includes people requiring emergency admission, and the assessment, investigation, and management of people who do not require emergency admission.
Scenario : Chronic breathlessness: covers the assessment and management of chronic breathlessness. This includes people requiring emergency admission, and the clinical assessment, investigation, and management of people who do not require emergency admission.
Scenario : Acute breathlessness
Scenario : Acute breathlessness
Emergency admission
Which people with acute breathlessness need emergency admission?
Determine the need for emergency admission by assessing the person's blood pressure, pulse, temperature, level of consciousness, peak expiratory flow rate (PEFR), oxygen saturation, and (if possible) electrocardiogram (ECG).
Arrange emergency admission for people with:
Respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
Peak expiratory flow rate (PEFR) less than 33% of predicted.
Altered level of consciousness.
A large respiratory effort (particularly if the person is becoming exhausted).
Stridor.
Clinical features of a pulmonary embolus or pneumothorax.
ECG suggesting a cardiac arrhythmia or myocardial infarction.
Consider arranging emergency admission, depending on the severity and number of risk factors present, if the person has acute breathlessness associated with any of the following:
Elevated respiratory rate (but if it is more than 30 breaths per minute, arrange emergency admission).
Tachycardia (but if it is more than 130 beats per minute, arrange emergency admission).
Hypotension (but if blood pressure is less than 90 mmHg systolic or 60 mmHg diastolic, arrange emergency admission).
High temperature (especially if it is higher than 38.5°C).
PEFR less than 50% of predicted (but if it is less than 33%, arrange emergency admission).
Older than 65 years of age.
Basis for recommendation
Basis for recommendation
Blood pressure, pulse rate, respiratory rate, temperature, and level of consciousness
The modified early warning system (MEWS), recommended by the British Thoracic Society (BTS), assesses and classifies the seriousness of the condition of an acutely unwell person (based on their blood pressure, pulse, temperature, breathing rate, and level of consciousness) to determine their need for urgent medical care [British Thoracic Society, 2008].
MEWS is based on evidence (from a prospective cohort study of 673 medical admissions) of the association between vital signs and level of consciousness, and the risk of death, risk of cardiac arrest, and need for treatment in a high dependency or intensive care unit [Subbe et al, 2001].
The CRB-65 scoring system, recommended by BTS, assesses the risk of harm for people with community-acquired pneumonia based on the presence of: confusion (recent); respiratory rate of 30 breaths/min or greater; blood pressure (systolic 90 mmHg or less, or diastolic 60 mmHg or less); and age (65 years of age or older) [Lim et al, 2009].
The CRB-65 assessment is based on evidence of the risk of death from a cohort study, that prospectively followed 1000 people who had been admitted to hospital with a primary diagnosis of community-acquired pneumonia [Lim et al, 2003].
The SIGN and BTS guideline The management of asthma recommends assessing the risk of harm for people with acute asthma based on respiratory rate, blood pressure, pulse rate, and level of consciousness (as well as their peak expiratory flow rate, oxygen saturation, presence of central cyanosis and signs of exhaustion) [SIGN and BTS, 2008].
This assessment is based on evidence from confidential enquires into over two hundred asthma deaths in the UK of the association between these clinical features and the risk of death in people presenting with acute severe asthma.
CKS takes the view that the similarity of the recommended methods of assessing risk in widely differing conditions can be taken as evidence that these methods of assessment can reasonably be extrapolated to all people who are acutely ill, whatever the cause, and to people with breathlessness where the cause is unknown.
Oxygen saturation less than 92%
The BTS guidelines for the management of community acquired pneumonia in adults: update 2009 recommend that pulse oximetry should be available to general practitioners to assess severity and oxygen requirement in people with community-acquired pneumonia and other acute respiratory illnesses [British Thoracic Society, 2009].
The Scottish Intercollegiate Guidelines Network (SIGN) and BTS guideline on the management of asthma recommends that people with asthma and oxygen saturation of less than 92% should be admitted to hospital as they are at high risk of death [SIGN and BTS, 2008].
Central cyanosis
Central cyanosis is reported to be present when the concentration of deoxygenated haemoglobin is more than 50 g/L. This corresponds to an arterial oxygen saturation of less than 90% in people who are not anaemic [Douglas and Bevan, 2009].
The SIGN and BTS guideline The management of asthma recommends that people with asthma and oxygen saturation of less than 92% should be admitted to hospital as they are at high risk of death [SIGN and BTS, 2008].
Stridor
Stridor is a sign of upper airway obstruction. It carries a high risk of death or serious morbidity. Experts recommend immediate admission [Zoorob and Campbell, 2003].
Peak expiratory flow rate (PEFR)
The SIGN and BTS guideline The management of asthma recommend that people with asthma and PEFR less than 30% of predicted, have life-threatening asthma; and recommends emergency admission [SIGN and BTS, 2008].
The guidelines also recommend that, for people with known asthma and PEFR less than 50% of predicted, the decision to admit should be based on their response to treatment and the risk of subsequent deterioration (based on their previous history).
These recommendations are based on evidence from confidential enquires into over two hundred asthma deaths in the UK that identified clinical features associated with an increased risk of death.
Other indications for admission
Suspected pulmonary embolism, pneumothorax, sudden-onset cardiac arrhythmia, or silent myocardial infarction are known to be associated with a high risk of death or serious morbidity. Experts recommend immediate admission [Zoorob and Campbell, 2003; Arrhythmia & Sudden Cardiac Death Subgroup, 2007].
Management - waiting for emergency admission
How should I manage someone with acute breathlessness waiting for emergency admission?
Sit the person up.
If the person has an oxygen saturation of less than 92%, give oxygen and continuously monitor their oxygen saturation levels while waiting for transfer to hospital.
ONLY USE A 28% VENTURI MASK AT 4 L/MIN FOR PEOPLE WITH SUSPECTED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), morbid obesity, a chest wall deformity, or a neuromuscular disorder. This is because they are at risk of hypercapnic respiratory failure.
For other people who are acutely ill, use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target oxygen saturation of 94–98%.
Identify and treat people with clinical features of:
Silent myocardial infarction: give aspirin 300 mg.
Give an intravenous diuretic, opioid, and anti-emetic (for example furosemide 40 mg to 80 mg, diamorphine 2.5 mg to 5.0 mg, and metoclopramide 10 mg).
Also give a nitrate, either sublingual or buccal (for example glyceryl trinitrate [GTN] spray, two puffs).
Supraventricular tachycardia (SVT). Attempt to terminate the arrhythmia, using a valsalva manoeuvre or carotid sinus massage. For further information, see the CKS topic on Palpitations.
Valsalva manoeuvre — ask the person to breathe out against a closed nose and mouth.
Carotid sinus massage — do not attempt this if the person is elderly, or has ischaemic heart disease, a carotid bruit, or a history of stroke or transient ischaemic attack. Only attempt one side at a time. Ensure that a defibrillator is available, as (very rarely) terminating an SVT can provoke other arrhythmias. Ideally, continuously monitor by electrocardiography (ECG), during the procedure as well as afterwards.
Acute severe asthma (peak expiratory flow rate less than 50% of predicted).
Give a bronchodilator (for example nebulized salbutamol 5 mg, or repeated doses of a metered-dose inhaler via a spacing device).
Give prednisolone 30 mg orally (if available).
Repeat the bronchodilator treatment as necessary.
For further information, see the CKS topic on Asthma.
Acute exacerbation of chronic obstructive pulmonary disease.
Give a bronchodilator (for example nebulized salbutamol 5 mg, or repeated doses of a metered-dose inhaler via a spacing device).
Give prednisolone 30 mg orally (if available).
Repeat the bronchodilator treatment as necessary.
For further information, see the CKS topic on Chronic obstructive pulmonary disease.
Tension pneumothorax: if the diagnosis is certain, and the person's condition is life threatening, consider inserting a large bore cannula through the second intercostal space in the mid-clavicular line, on the side of the pneumothorax.
Basis for recommendation
Basis for recommendation
Oxygen therapy
Recommendations are based on expert opinion published in guidelines by the British Thoracic Society [British Thoracic Society, 2008].
Management of SVT
Recommendations are based on expert opinion published in the Thames valley cardiac network protocol for the management of palpitations in primary care [Arrhythmia & Sudden Cardiac Death Subgroup, 2007].
Management of acute severe asthma
Recommendations are based on expert opinion published in the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2008].
Management of pulmonary oedema
Recommendations are based on expert opinion reported in the Oxford handbook of general practice [Simon et al, 2010].
Management of an acute exacerbation of COPD
Recommendations are based on expert opinion published in Chronic obstructive pulmonary disease: national clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care [NICE, 2010].
Management of tension pneumothorax
Recommendations are based on expert opinion reported in the Oxford handbook of general practice [Simon et al, 2010].
Management - emergency admission NOT required
How should I manage someone with acute breathlessness who does not need emergency admission?
If the person does not have an indication for emergency admission:
Look for clinical features of:
Acute asthma, especially in people with wheeze or cough that is worse at night, or upon exercise or exposure to allergens.
An acute exacerbation of chronic obstructive pulmonary disease (COPD), especially in people older than 35 years of age who smoke (or who have smoked), particularly if they have wheeze and a new or worsening cough.
Pneumonia, especially in people with a cough and at least one other symptom of sputum, wheeze, fever, or pleuritic pain.
Lung/lobar collapse, especially in people with a history of cancer with lymph node involvement, an inhaled foreign body, or debility causing retained airway secretions.
Pleural effusion, especially in people with: heart, liver, or renal failure; cancer; tuberculosis; or pleural infection.
Psychogenic breathlessness, especially in people who have no clinical features of a physical cause for breathlessness.
Arrange investigations to confirm a suspected cause, or to identify the cause when the cause is uncertain.
Manage the underlying cause of breathlessness. For people with:
Acute asthma — see the CKS topic on Asthma.
Acute exacerbation of COPD — see the CKS topic on Chronic obstructive pulmonary disease.
Bronchiectasis — see the CKS topic on Bronchiectasis.
Community-acquired pneumonia — see the CKS topic on Chest infections - adult.
Lung/lobar collapse — refer the person to a respiratory specialist for investigation of the underlying cause.
Pleural effusion — refer (or admit) the person, for drainage of the effusion and investigation of the underlying cause.
Psychogenic breathlessness:
Explain that the person's symptoms are due to anxiety and hyperventilation.
Advise the person to try to control their breathing rate (by counting breaths in and out gently), slowing it down.
Manage any persistent symptoms of hyperventilation, using a bag to re-breathe expired air.
Consider management of any underlying anxiety disorder.
Consider referral to a respiratory physiotherapist, so the person can learn methods of controlling breathlessness.
For people with acute breathlessness that remains of uncertain cause, reassess for risk factors and clinical features of pulmonary embolism. Arrange urgent referral for further investigations if pulmonary embolism is suspected.
Basis for recommendation
Basis for recommendation
Investigations to confirm the cause
Experts recommend arranging investigations to confirm the cause for acute breathlessness, because individual symptoms and signs associated with breathlessness are insufficiently specific to confirm the cause [Hopkin, 2010].
Lung/lobar collapse
CKS recommends referral for people with lung/lobar collapse, for specialist investigations to determine the cause.
Pleural effusion
CKS recommends admission or referral for people with a pleural effusion and breathlessness, for specialist treatment to drain the effusion and investigate the underlying cause.
Psychogenic breathlessness
Recommendations are based on expert opinion reported in the Oxford handbook of general practice [Simon et al, 2010].
Investigations
How should I investigate people with acute breathlessness?
If the person does not have an indication for emergency admission, arrange investigations to identify or confirm the underlying cause of breathlessness.
Acute breathlessness of uncertain cause
Chest radiography — to look for signs of heart failure and pulmonary pathology (including pleural effusion).
Electrocardiogram (ECG) — to look for signs of heart failure, arrhythmia, and pulmonary embolism.
Spirometry or peak expiratory flow rate — to look for signs of obstructive airway disease.
Full blood count — to check for anaemia.
C-reactive protein or erythrocyte sedimentation rate (ESR) — for evidence of infection.
Other investigations guided by clinical findings.
Suspected acute asthma or an acute exacerbation of chronic obstructive airways disease (COPD)
Assess airways obstruction by spirometry. Airway obstruction is confirmed by a forced expiratory volume in 1 second (FEV1) less than 80% of the predicted value and FEV1/forced vital capacity (FVC) ratio less than 70%.
Distinguish asthma from COPD, based on:
Smoking history — almost always present in people with COPD.
Age — usually older than 35 years of age for COPD.
Chronic productive cough — common with COPD, uncommon with asthma.
Breathlessness — progressive with COPD, variable with asthma.
Variability of symptoms — common with asthma, uncommon with COPD.
If asthma and COPD cannot be distinguished based on clinical features:
Arrange measurements of peak expiratory flow rate (PEFR) — morning and night-time measurements, and during symptoms (to assess variability).
If doubt still remains, a large response (greater than 400 mL) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma; but not COPD.
If doubt still remains, refer the person for a specialist's opinion.
For people with COPD, arrange chest radiography to exclude other serious lung pathology (such as lung cancer).
Suspected acute exacerbation of bronchiectasis. Arrange chest radiography to exclude other causes for the symptoms. Refer the person to a respiratory specialist for confirmation of the diagnosis (by high resolution computed tomography scanning).
Suspected pneumonia. Arrange chest radiography if the person is older than 50 years of age and smokes (to exclude underlying cancer). For other people who are well enough to be managed in the community, chest radiography is not required to confirm the diagnosis.
Suspected lung/lobar collapse. Arrange chest radiography to confirm the diagnosis.
Suspected pleural effusion. Arrange chest radiography to confirm the diagnosis.
Basis for recommendation
Basis for recommendation
Investigating acute breathlessness of uncertain cause
Recommended investigations are based on expert opinion to identify the common causes of acute breathlessness [Zoorob and Campbell, 2003].
Investigating suspected acute asthma or an acute exacerbation of COPD
Investigations to confirm the diagnosis and distinguish COPD from asthma are based on expert opinion reported in the British Guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2008] and Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care [NICE, 2010].
Investigating suspected acute exacerbation of bronchiectasis
Recommendations are based on expert opinion reported in the British thoracic society guideline for non-CF Bronchiectasis [British Thoracic Society, 2010].
Investigating suspected lung/lobar collapse or pleural effusion
Chest radiography is recommended by experts because of the lack of reliability of clinical findings to confirm the diagnosis [Gibson, 2010].
Investigating suspected community-acquired pneumonia
Recommendations on when investigations are appropriate in people who are well enough to be managed in the community are based on expert opinion reported in British Thoracic Society guidelines on The management of community acquired pneumonia [British Thoracic Society, 2001; British Thoracic Society, 2009].
Scenario : Chronic breathlessness
Scenario : Chronic breathlessness
Emergency admission
Which people with chronic breathlessness need emergency admission?
Emergency admission is most commonly required when a new acute problem (such as a respiratory tract infection, pulmonary embolism, or sudden-onset arrhythmia) exacerbates breathlessness caused by a chronic condition (such as chronic obstructive pulmonary disease or chronic heart failure).
Determine the need for emergency admission by assessing the person's blood pressure, pulse, temperature, level of consciousness, peak expiratory flow rate (PEFR), oxygen saturation, and (if possible) electrocardiogram (ECG).
Arrange emergency admission for people with:
Respiratory rate of more than 30 breaths per minute.
Tachycardia greater than 130 beats per minute.
Systolic blood pressure less than 90 mmHg, or diastolic blood pressure less than 60 mmHg (unless this is normal for them).
Oxygen saturation less than 92%, or central cyanosis (if the person has no history of chronic hypoxia).
Peak expiratory flow rate (PEFR) less than 33% of predicted.
Altered level of consciousness.
A large respiratory effort (particularly if the person is becoming exhausted).
Stridor.
Clinical features of a pulmonary embolus or pneumothorax.
ECG suggesting a cardiac arrhythmia or myocardial infarction.
Consider arranging emergency admission, depending on the severity and number of risk factors present, if the person has breathlessness associated with any of the following:
Elevated respiratory rate (but if it is more than 30 breaths per minute, arrange emergency admission).
Tachycardia (but if it is more than 130 beats per minute, arrange emergency admission).
Hypotension (but if blood pressure is less than 90 mmHg systolic or 60 mmHg diastolic, arrange emergency admission).
A high temperature (particularly if it is higher than 38.5°C).
PEFR less than 50% of predicted (but if it is less than 33%, arrange emergency admission).
Older than 65 years of age.
Basis for recommendation
Basis for recommendation
Blood pressure, pulse rate, respiratory rate, temperature, and level of consciousness
The modified early warning system (MEWS), recommended by the British Thoracic Society (BTS), assesses and classifies the seriousness of the condition of an acutely unwell person (based on their blood pressure, pulse, temperature, breathing rate, and level of consciousness) to determine their need for urgent medical care [British Thoracic Society, 2008].
MEWS is based on evidence (from a prospective cohort study of 673 medical admissions) of the association between vital signs and level of consciousness, and the risk of death, risk of cardiac arrest, and need for treatment in a high dependency or intensive care unit [Subbe et al, 2001].
The CRB-65 scoring system, recommended by BTS, assesses the risk of harm for people with community-acquired pneumonia based on the presence of: confusion (recent); respiratory rate of 30 breaths/min or greater; blood pressure (systolic 90 mmHg or less, or diastolic 60 mmHg or less); and age (65 years of age or older) [Lim et al, 2009].
The CRB-65 assessment is based on evidence of the risk of death from a cohort study, that prospectively followed 1000 people who had been admitted to hospital with a primary diagnosis of community-acquired pneumonia [Lim et al, 2003].
The SIGN and BTS guideline The management of asthma recommends assessing the risk of harm for people with acute asthma based on respiratory rate, blood pressure, pulse rate, and level of consciousness (as well as their peak expiratory flow rate, oxygen saturation, presence of central cyanosis and signs of exhaustion) [SIGN and BTS, 2008].
This assessment is based on evidence from confidential enquires into over two hundred asthma deaths in the UK of the association between these clinical features and the risk of death in people presenting with acute severe asthma.
CKS takes the view that the similarity of the recommended methods of assessing risk in widely differing conditions can be taken as evidence that these methods of assessment can reasonably be extrapolated to all people who are acutely ill, whatever the cause, and to people with breathlessness where the cause is unknown.
Oxygen saturation less than 92%
The BTS guidelines for the management of community acquired pneumonia in adults: update 2009 recommend that pulse oximetry should be available to general practitioners to assess severity and oxygen requirement in people with community-acquired pneumonia and other acute respiratory illnesses [British Thoracic Society, 2009].
The Scottish Intercollegiate Guidelines Network (SIGN) and BTS guideline on the management of asthma recommends that people with asthma and oxygen saturation of less than 92% should be admitted to hospital as they are at high risk of death [SIGN and BTS, 2008].
Central cyanosis
Central cyanosis is reported to be present when the concentration of deoxygenated haemoglobin is more than 50 g/L. This corresponds to an arterial oxygen saturation of less than 90% in people who are not anaemic [Douglas and Bevan, 2009].
The SIGN and BTS guideline The management of asthma recommends that people with asthma and oxygen saturation of less than 92% should be admitted to hospital as they are at high risk of death [SIGN and BTS, 2008].
Stridor
Stridor is a sign of upper airway obstruction. It carries a high risk of death or serious morbidity. Experts recommend immediate admission [Zoorob and Campbell, 2003].
Peak expiratory flow rate (PEFR)
The SIGN and BTS guideline The management of asthma recommend that people with asthma and PEFR less than 30% of predicted, have life-threatening asthma; and recommends emergency admission [SIGN and BTS, 2008].
The guidelines also recommend that, for people with known asthma and PEFR less than 50% of predicted, the decision to admit should be based on their response to treatment and the risk of subsequent deterioration (based on their previous history).
These recommendations are based on evidence from confidential enquires into over two hundred asthma deaths in the UK that identified clinical features associated with an increased risk of death.
Other indications for admission
Suspected pulmonary embolism, pneumothorax, sudden-onset cardiac arrhythmia, or silent myocardial infarction are known to be associated with a high risk of death or serious morbidity. Experts recommend immediate admission [Zoorob and Campbell, 2003; Arrhythmia & Sudden Cardiac Death Subgroup, 2007].
Management - waiting for emergency admission
How should I manage someone with chronic breathlessness waiting for emergency admission?
Sit the person up.
If the person has an oxygen saturation of less than 92%, give oxygen and continuously monitor their oxygen saturation levels while waiting for transfer to hospital.
ONLY USE A 28% VENTURI MASK AT 4 L/MIN FOR PEOPLE WITH SUSPECTED CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD), morbid obesity, a chest wall deformity, or a neuromuscular disorder. This is because they are at risk of hypercapnic respiratory failure.
For other people who are acutely ill, use a simple face mask. Adjust the flow rate to 5–10 L/min to achieve a target oxygen saturation of 94–98%.
Basis for recommendation
Basis for recommendation
Recommendations for oxygen therapy are based on expert opinion published in guidelines by the British Thoracic Society [British Thoracic Society, 2008].
Management - emergency admission NOT required
How should I manage someone with chronic onset breathlessness who does not need emergency admission?
If the person does not have an indication for emergency admission:
Look for clinical features of:
Chronic heart failure, especially if the person has a history of ischaemic or valvular heart disease, hypertension, or the onset of chronic cardiac arrhythmias (such as atrial fibrillation).
Asthma, especially in people with wheeze or cough that is worse at night, or upon exercise or exposure to allergens.
An acute exacerbation of chronic obstructive pulmonary disease (COPD), especially in people older than 35 years of age who smoke (or who have smoked), particularly if they have wheeze and a new or worsening cough.
Bronchiectasis, especially in non-smokers with chronic progressive breathlessness that is associated with either a chronic productive cough or recurrent chest infections.
Interstitial lung disease, especially in people with a history of exposure to asbestos, dust (such as coal dust), birds, hay, or mushrooms.
Pleural effusion, especially in people with: heart, liver, or renal failure; cancer; tuberculosis; or pleural infection.
Abdominal splinting secondary to obesity or ascites.
Arrange investigations to confirm the cause of breathlessness.
Manage the underlying cause of chronic breathlessness. For people with:
Chronic heart failure — see the CKS topic on Heart failure - chronic.
Asthma — see the CKS topic on Asthma.
COPD — see the CKS topic on Chronic obstructive pulmonary disease.
Bronchiectasis — see the CKS topic on Bronchiectasis.
Restrictive lung disease — refer the person to a respiratory specialist for assessment and management of the cause.
Pleural effusion — refer (or admit) the person, for drainage and investigations of the underlying cause of the effusion.
Anaemia — see the CKS topics on:
Anaemia - B12 and folate deficiency.
Diaphragmatic splinting that is secondary to:
Obesity — see the CKS topic on Obesity.
Ascites — refer the person to an appropriate specialist for management of the underlying cause.
For people with chronic breathlessness that remains of uncertain cause, reassess for risk factors and clinical features of pulmonary embolism:
If pulmonary embolism is suspected, arrange urgent referral.
If pulmonary embolism seems unlikely, arrange routine referral.
Basis for recommendation
Basis for recommendation
Investigations to confirm the cause
Experts recommend arranging investigations to confirm the cause of breathlessness, because individual symptoms and signs associated with breathlessness are insufficiently specific to confirm a diagnosis [Hopkin, 2010].
Management of people with interstitial lung disease
CKS recommends referral for people with breathlessness associated with a restrictive pattern on spirometry (suggestive of interstitial lung disease) because specialist investigations are needed to determine the cause.
Management of pleural effusion
CKS recommends referral or admission for people with pleural effusions large enough to cause breathlessness, because specialist treatment is needed to drain the effusion and investigate the cause.
Management of abdominal splinting caused by ascites
CKS recommends referral for people with ascites because specialist treatment is needed for drainage and to investigate the underlying cause.
Investigations
How should I investigate people with chronic breathlessness?
If the person does not have an indication for emergency admission, arrange investigations to identify or confirm the underlying cause of breathlessness.
Where the diagnosis cannot confidently be established by clinical features alone:
Initial investigations should include:
Chest radiography — to look for signs of heart failure and pulmonary pathology (including pleural effusion).
Electrocardiography (ECG) — to look for signs of heart failure, arrhythmia, and pulmonary embolism.
Spirometry — to look for signs of obstructive airway disease or a restrictive pattern associated with interstitial lung disease (such as idiopathic pulmonary fibrosis, sarcoidosis, pneumoconiosis, or extrinsic allergic alveolitis).
Full blood count — to check for anaemia.
Urea and electrolytes, and random blood glucose level — to test for renal failure and diabetes as causes of metabolic acidosis and breathlessness.
Thyroid function tests — to detect thyroid disease as a cause of breathlessness.
If initial investigations do not identify the cause of breathlessness:
Arrange echocardiography and test for B-type natriuretic peptide (BNP), depending on local guidelines, to assess for heart failure.
Reassess for risk factors and clinical features of pulmonary embolism. If this is suspected, arrange urgent referral for further investigations.
Suspected asthma or COPD
Assess airways obstruction by spirometry. Airway obstruction is confirmed by a forced expiratory volume in 1 second (FEV1) less than 80% of the predicted value and FEV1/forced vital capacity (FVC) ratio less than 70%.
Distinguish asthma from COPD, based on:
Smoking history — almost always present in people with COPD.
Age — usually older than 35 years of age for COPD.
Chronic productive cough — common with COPD, uncommon with asthma.
Breathlessness — progressive with COPD, variable with asthma.
Variability of symptoms — common with asthma, uncommon with COPD.
If asthma and COPD can not be distinguished based on clinical features:
Arrange measurements of peak expiratory flow rate (PEFR) — morning and night-time measurements, and during symptoms (to assess variability).
If doubt still remains, a large response (more than 400 mL) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma; but not COPD.
If doubt still remains, refer the person for a specialist's opinion.
For people with COPD, arrange chest radiography (to exclude other serious lung pathology, such as lung cancer) and full blood count (to identify polycythaemia/erythrocytosis secondary to chronic hypoxia).
Suspected bronchiectasis. Arrange chest radiography to exclude other causes for the symptoms, and refer the person to a respiratory specialist for confirmation of the diagnosis (by high resolution computed tomography scanning).
Suspected pleural effusion. Arrange chest radiography to confirm the diagnosis.
Suspected abdominal splinting secondary to ascites. Arrange an abdominal ultrasound scan to confirm the presence of ascites and to exclude or confirm liver cirrhosis and peritoneal cancer. Arrange other investigations guided by clinical findings (for example liver function tests or erythrocyte sedimentation rate; for signs of cancer).
Basis for recommendation
Basis for recommendation
Investigating chronic breathlessness of uncertain cause
Initial investigations. These tests are recommended by CKS based on their availability in primary care and their effectiveness for identifying an underlying cause.
Echocardiography. CKS recommends limiting the use of echocardiography/BNP to when initial investigations do not fully identify the cause of chronic breathlessness; to make the most effective use of these resources.
Investigating suspected acute asthma or an acute exacerbation of COPD
Investigations to confirm the diagnosis and distinguish COPD from asthma are based on expert opinion reported in the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2008] and Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care [NICE, 2010].
Investigating suspected bronchiectasis
Recommendations are based on expert opinion reported in the British thoracic society guideline for non-CF bronchiectasis [British Thoracic Society, 2010].
Investigating suspected bronchiectasis
Recommendations are based on expert opinion reported in the British thoracic society guideline for non-CF bronchiectasis [British Thoracic Society, 2010].
Investigating suspected pleural effusion
Chest radiography is recommended by experts, because of the lack of reliability of clinical findings to confirm the diagnosis [Gibson, 2010].
Investigating suspected diaphragmatic splinting secondary to ascites
CKS recommends arranging an abdominal ultrasound scan to confirm the presence of ascites and investigate the underlying cause.
Evidence
Evidence
Supporting evidence
CKS identified no guidelines or studies specifically about the management of people presenting with breathlessness in primary care. The recommendations in this CKS topic are mainly based on expert opinion and observations in medical reference books.
The evidence on the emergency management of asthma, chronic obstructive pulmonary disease, community-acquired pneumonia in adults, and supraventricular tachycardia, as well as the emergency use of oxygen can be found in guidelines from the British Thoracic Society and the Scottish Intercollegiate Guideline Network [SIGN and BTS, 2008], the National Institute for Health and Clinical Excellence [National Clinical Guideline Centre, 2010], the British Thoracic Society [British Thoracic Society, 2001; British Thoracic Society, 2008], and the Arrhythmia & Sudden Death Cardiac Subgroup [Arrhythmia & Sudden Cardiac Death Subgroup, 2007].
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews, randomized controlled trials and background reviews on primary care management of breathlessness/dyspnea, with additional searches in the following areas:
Assessment
Diagnosis
Causes of breathlessness
Psychogenic breathlessness
The search excluded children and breathlessness associated with palliative care patients.
Search dates
January 1990 – March 2010
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Dyspnea/, dyspnoea.tw, breathless$.tw
exp Respiration Disorders/, Pulmonary consolidation.tw, exp Hemothorax/, exp Pneumothorax/, exp Lung Neoplasms/, exp Pulmonary Edema/, exp Airway Obstruction/, exp Pulmonary Embolism/, exp Pleural Effusion/, exp Pneumonia/
exp Oximetry/, exp X-Rays/, exp Fibrin Fibrinogen Degradation Products/, exp Spirometry/
exp Panic Disorders/, psychogenic breathlessness.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Topic specific literature search sources
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
National Guidelines Clearinghouse
British Columbia Medical Association
Institute for Clinical Systems Improvement
Guidelines International Network
National Library of Guidelines
National Health and Medical Research Council (Australia)
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Plus (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
DynaMed
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
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