St Emlyn’s Lesson Plans
The breathless patient: act, assess, reassess
Discuss initial care for breathlessness, oxygen targets and the different options for a stable pneumothorax.
New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 15 minutes in total.
When we meet: We will discuss acute pulmonary oedema and a patient with a large pneumothorax who is now comfortable.
For facilitators
Send: the learner preparation link before teaching.
Bring: Linked oxygen and pneumothorax guidance, and the written imaging findings in case two. Oxygen devices are optional for demonstration; no separate imaging report is required.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 15 minutes in total.
Core preparation
BTS: Oxygen in healthcare and emergency settings · About 6 minutes
Read the BTS oxygen target-range summary and the indications for blood-gas assessment. Note what should be monitored after oxygen is started.
https://www.brit-thoracic.org.uk/clinical-resources/guidelines/emergency-oxygen/
BTS: Pleural disease guideline 2023 · About 6 minutes
Read the current BTS spontaneous-pneumothorax pathway. Focus on the options for a minimally symptomatic patient and the follow-up each requires.
https://www.brit-thoracic.org.uk/clinical-resources/guidelines/pleural-disease/
Think about (allow 3 minutes): What would you reassess after starting oxygen, and when might you change the target?
Picture the scene
A breathless patient arrives in a busy resuscitation area. Your senior asks you to begin the assessment and call them immediately if you are concerned.
By the end of the session
- Recognise respiratory distress and call for appropriate support.
- Use controlled oxygen and targeted assessment without anchoring on one diagnosis.
- Apply current principles to acute pulmonary oedema and spontaneous pneumothorax.
After the session
- Find out how your department arranges next-day respiratory follow-up.
- For your next breathless patient, state the leading alternative diagnosis out loud to a colleague.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 15 minutes in total.
Before learners arrive
- Bring current oxygen, NIV and spontaneous-pneumothorax pathways.
- Confirm who can support NIV and pleural procedures and what follow-up the respiratory service offers.
- Use an approved local image if available; the written report is sufficient.
Equipment: Linked oxygen and pneumothorax guidance, and the written imaging findings in case two. Oxygen devices are optional for demonstration; no separate imaging report is required.
Setup: Pairs make an initial plan for the breathless patient, then reconsider it when tiring and acidaemia are revealed. Compare that urgency with the options in the stable pneumothorax case.
If the preparation has not been completed
Replace severity recognition and oxygen-target setting (12 minutes). Use the BTS oxygen summary and spontaneous-pneumothorax pathway linked above: eight minutes reading and four minutes comparing the decisions for the two cases. The facilitator brings the documents; oxygen devices are optional. For the 30-minute version, use the first nine minutes for a six-minute shared read and three-minute comparison, replacing severity recognition and oxygen-target setting.
Suggested session plan
- 0–5 min — Recognise the sick patient. Ask which clinical features require help before tests.
- 5–12 min — Set an oxygen target. Pairs explain what they will monitor and why.
- 12–35 min — Two cases. Contrast physiological urgency with a stable patient’s options.
- 35–40 min — Consolidate. Revisit what changed from the old pneumothorax approach.
- 40–45 min — Choose a follow-up action. Identify a local access or follow-up issue.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Awoken by breathlessness
A 65-year-old is acutely breathless with bilateral crackles, BP 180/90 and low oxygen saturation.
Add this information as the discussion develops:
- They are tiring and an appropriate blood-gas assessment shows acidaemia.
Ask the group:
- What will you do before the diagnosis is certain?
- Which findings support or challenge pulmonary oedema?
- When do you need senior respiratory or critical-care support?
Discussion notes
Points to draw out:
- Assess ABCDE, monitor, provide oxygen to the appropriate target and seek early senior help; do not withhold necessary oxygen while arranging blood gases.
- Consider ECG, chest imaging, focused ultrasound where competent and alternative causes. Acute heart failure is a working diagnosis, not a conclusion from hypertension alone.
- Treat according to the acute-heart-failure pathway. Nitrates are selected treatments, not routine for every patient; ventilatory support is based on severity, acidaemia and response, not simply a high venous CO2.
Common misconceptions:
- Giving the same oxygen and nitrate treatment to every breathless patient regardless of physiology and contraindications.
- Interpreting a venous gas as a complete assessment of oxygenation.
For a more experienced group: Discuss how hypotension, valve disease or concurrent ischaemia changes the plan.
A large pneumothorax in a comfortable patient
A young adult has sudden unilateral chest discomfort and breathlessness. Imaging confirms a primary spontaneous pneumothorax.
Add this information as the discussion develops:
- They are now minimally symptomatic with no physiological compromise; the radiograph describes a large pneumothorax.
Ask the group:
- Does size alone mandate a drain?
- What must be checked before considering conservative or ambulatory care?
- How would the plan change with deterioration?
Discussion notes
Points to draw out:
- BTS 2023 permits consideration of conservative treatment for selected minimally symptomatic primary spontaneous pneumothorax regardless of size.
- Discuss symptoms, stability, patient preference, support and dependable follow-up with the appropriate team; ambulatory care needs local expertise and infrastructure.
- Tension physiology or deterioration needs emergency treatment by a competent team and should not wait for routine imaging.
Common misconceptions:
- Declaring pneumothorax the only dangerous possibility because the patient is young and has no obvious PE risk factors.
- Applying the 2010 size threshold without considering the current pathway.
For a more experienced group: Contrast primary with secondary spontaneous pneumothorax; ask why the same discharge plan may be inappropriate.
Important clinical points
- BTS usual targets are 94–98% for most acutely ill adults and 88–92% for those at risk of hypercapnic respiratory failure pending blood gases; immediately treat critical hypoxaemia while seeking support.
- A normal oxygen saturation does not exclude PE or other serious disease.
- Do not wait for a radiograph in a patient with clinically suspected tension pneumothorax and instability.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- When would you revise an oxygen target?
- Why is a venous CO2 result insufficient to decide all respiratory care?
- What makes conservative pneumothorax care safe?
Key teaching points:
- Set an appropriate oxygen target and reassess the response.
- Check whether the findings fit the working diagnosis and consider alternatives.
- For a stable pneumothorax, consider symptoms, underlying disease and follow-up as well as the image.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Conservative and ambulatory pneumothorax care require patient selection and a functioning pathway; local access affects which option is safe.
If the discussion drifts
How sick is the patient now, and what response are we expecting?
For a more experienced group
Ask experienced learners to explain NIV selection, escalation if it fails and the limits of focused ultrasound.
A 30-minute version
30 minutes: severity 4; oxygen 5; pulmonary-oedema case 10; pneumothorax case 8; reflection 3. Omit the device demonstration.
Evidence and guidance
- BTS: Oxygen in healthcare and emergency settings — Controlled oxygen to a target range, including patients at risk of hypercapnic respiratory failure.https://www.brit-thoracic.org.uk/clinical-resources/guidelines/emergency-oxygen/
- BTS: Pleural disease guideline 2023 — Current spontaneous-pneumothorax pathways supersede the 2010 size-led algorithm.https://www.brit-thoracic.org.uk/clinical-resources/guidelines/pleural-disease/
- BTS: Pleural disease guideline, full supplement — Selected minimally symptomatic primary spontaneous pneumothorax can be managed conservatively regardless of size.https://www.brit-thoracic.org.uk/document-library/guidelines/pleural-disease/pleural-disease-full-supplement/
- NICE CG187: Acute heart failure — Acute treatment, selected use of nitrates and ventilatory support.https://www.nice.org.uk/guidance/cg187
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO1 Care for physiologically stable adults with acute presentations
Safe assessment, differential diagnosis and disposition.
RCEM 2021 curriculum (2025 update): SLO3 Resuscitate and stabilise adults
Recognition, prioritisation and team escalation.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
Clinical review: awaiting clinician sign-off
The references have been checked during editing. A named clinician has not yet signed off the revised lesson collection. Use current local guidance when preparing to teach; editorial updates do not constitute clinical approval.
First published 2020-06-07 · Iain Beardsell.