St Emlyn’s Lesson Plans
Assessing acute breathlessness
Recognise respiratory compromise and compare acute heart failure with pneumothorax without relying on age or a single measurement.
Medical Students · 45-minute session
For learners
Before: Allow about 12 minutes in total.
When we meet: We will assess acute heart failure and two pneumothorax presentations, considering oxygen requirement, physiological compromise and the response to treatment.
Practise: use the practice card with a partner.
For facilitators
Send: the learner preparation link before teaching.
Bring: Board for comparing saturation and oxygen requirement, written case reports and current pathways; an appropriately licensed chest radiograph is optional.
Run: 45-minute session plan · 30-minute option
Practise: use the card for observed practice and feedback. Allow time for both turns, or arrange a follow-on practice session.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.
Core preparation
RCUK ABCDE approach · About 4 minutes
Read only “Breathing (B)”, including the oxygen guidance. Focus on respiratory effort, oxygen device or flow, and the information a saturation reading cannot provide.
https://www.resus.org.uk/library/abcde-approach
NICE CG187 acute heart failure · About 3 minutes
Read 1.3.2–1.3.8 on initial drug treatment and 1.4.1–1.4.2 on non-invasive ventilation. Focus on diuretics, when nitrates may be considered and the circumstances that prompt NIV.
https://www.nice.org.uk/guidance/cg187/chapter/recommendations
BTS pleural disease guideline 2023 · About 3 minutes
Under the 2023 guideline resources, open “Appendix 1: Clinical Pathways/decision trees” and read the pneumothorax pathway only. Focus on symptoms and physiological compromise, not the pleural infection or malignancy pathways.
https://www.brit-thoracic.org.uk/clinical-resources/guidelines/pleural-disease/
Think about (allow 2 minutes): What else do you need to know before calling an oxygen saturation of 95% reassuring?
Picture the scene
A person arrives breathless at the end of your shift. Their oxygen saturation looks acceptable, but only while receiving a high concentration of oxygen.
By the end of the session
- Assess work of breathing, oxygen requirement and deterioration alongside saturation.
- Explain the initial priorities in possible acute heart failure.
- Use symptoms and physiological risk, rather than size alone, when discussing pneumothorax management.
After the session
- During your next breathlessness assessment, include oxygen device/flow and work of breathing in the first sentence of your handover.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 12 minutes in total.
Before learners arrive
- Check local oxygen, NIV and pleural pathways; obtain senior respiratory/critical-care contacts.
- Use the current BTS pathway and remove older size-only algorithms from teaching.
Equipment: Board for comparing saturation and oxygen requirement, written case reports and current pathways; an appropriately licensed chest radiograph is optional.
Setup: Pairs compare the same saturation on different oxygen devices, then agree the next action and explain their reasoning.
If the preparation has not been completed
Replace the five-minute “Establish the essentials” slot. Write “95% on air” and “95% on high-concentration oxygen” on the board. Give pairs two minutes to explain what each leaves unknown, two to compare the oxygen guidance with the first case, and one to identify signs needing urgent help. Introduce the heart-failure and pneumothorax pathways during their cases.
Suggested session plan
- 0–5 min — Explore. Ask which information is missing from a saturation number.
- 5–10 min — Establish the essentials. Review oxygen assessment and targets before applying the two pathways in their cases.
- 10–32 min — Discuss & Apply. Use 12 minutes for heart failure and 10 for pneumothorax.
- 32–40 min — Consolidate. Ask pairs to compare the same saturation on air and on oxygen, then justify the two different pneumothorax plans.
- 40–45 min — Reflect & Transfer. Have learners rehearse a breathlessness handover that includes oxygen device or flow and work of breathing.
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.
Waking up breathless
A 65-year-old wakes with severe breathlessness, feels unable to lie flat and arrives hypertensive and distressed. Saturation is 95% on oxygen; there are bilateral crackles.
Add this information as the discussion develops:
- ECG and chest imaging support acute heart failure, but the cause and baseline function remain uncertain.
- The patient develops severe dyspnoea and acidaemia despite initial treatment.
Ask the group:
- What must be assessed and treated while taking the history?
- Which alternatives or precipitants still need consideration?
- What changes the need for respiratory support?
Discussion notes
Points to draw out:
- Assess ABC, work of breathing, oxygen requirement and perfusion; seek senior help early. Consider ischaemia, arrhythmia and other precipitants rather than assuming the label explains everything.
- Use oxygen to a defined target and assess gas exchange when appropriate. Typical targets are 94–98%, or 88–92% in people at risk of hypercapnic respiratory failure pending assessment; immediately life-threatening hypoxaemia requires urgent oxygen and resuscitation.
- NICE recommends IV diuretic therapy in acute heart failure. Nitrates are not routine for all patients but may be used in selected circumstances with close monitoring.
- NIV is not restricted to hypercapnia: consider it without delay in cardiogenic pulmonary oedema with severe dyspnoea and acidaemia, under the experienced team.
Common misconceptions:
- Calling 95% reassuring without noting the oxygen device.
- Treating hypertension plus breathlessness as a complete diagnosis.
- Giving routine nitrate or opioid therapy to every acute heart-failure patient.
For a more experienced group: Ask how hypotension, valvular disease or a treatment-escalation plan changes the discussion.
A young adult with pleuritic pain
A 25-year-old has sudden unilateral pain and breathlessness. Imaging confirms a primary spontaneous pneumothorax.
Add this information as the discussion develops:
- Version A: the patient is minimally symptomatic with no physiological compromise and reliable follow-up is available.
- Version B: there is worsening distress and haemodynamic compromise.
Ask the group:
- Does a ‘large’ measurement alone dictate drainage in version A?
- What changes urgency in version B?
- Why should the differential not have been narrowed just because the patient is young?
Discussion notes
Points to draw out:
- BTS 2023 allows consideration of conservative management for minimally symptomatic primary spontaneous pneumothorax without physiological compromise, irrespective of size; shared decisions and dependable follow-up matter.
- Deterioration requires immediate senior assessment. Suspected tension physiology is a clinical emergency; do not wait for confirmatory imaging before appropriate expert treatment.
- Consider PE, cardiac disease and other serious causes in younger adults when the presentation fits.
Common misconceptions:
- Using an obsolete size-only flowchart.
- Assuming every spontaneous pneumothorax is suitable for observation.
- Waiting for tracheal deviation before recognising severe compromise.
For a more experienced group: Discuss why secondary pneumothorax and underlying lung disease require a different risk assessment.
Important clinical points
- Do not withhold urgently needed oxygen because hypercapnia is possible; assess and titrate with appropriate monitoring.
- A normal saturation does not exclude PE or major respiratory disease.
- Do not base pneumothorax intervention solely on an old size threshold.
Practise with a partner
Use the card to rehearse the skill together. One learner performs. One learner checks the key steps and gives feedback. Then swap roles.
Respiratory examination · MLA
Practise with a partnerRead the observer setup and allow time for both turns. Use the card alongside the lesson activity or in a follow-on practice session.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Explain why 95% on high-concentration oxygen differs from 95% on air.
- State why routine nitrates are not the answer for every heart-failure presentation.
- Contrast the two pneumothorax decisions.
Key teaching points:
- Assess work of breathing and oxygen requirement alongside the saturation.
- Treat the likely cause while reviewing the physiological response.
- Pneumothorax decisions depend on symptoms, stability and reliable follow-up as well as imaging.
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
A syndrome such as pulmonary oedema still has an underlying cause. Several diagnoses may coexist; reassess when treatment fails.
If the discussion drifts
Is the patient improving, and what support do they need to remain stable?
For a more experienced group
Compare CPAP/NIV indications and escalation limits without turning the discussion into unsupervised device training.
A 30-minute version
30 minutes: opening 3, oxygen check 5, cases 15, consolidation 5, reflection 2.
Evidence and guidance
- RCUK ABCDE approach — Assessment and oxygen targets.https://www.resus.org.uk/library/abcde-approach
- NICE CG187 — Acute heart-failure treatment and NIV.https://www.nice.org.uk/guidance/cg187/chapter/recommendations
- BTS pleural disease 2023 — Contemporary spontaneous pneumothorax guidance.https://www.brit-thoracic.org.uk/clinical-resources/guidelines/pleural-disease/
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Breathlessness; heart failure and pneumothorax
Recognising acute compromise and explaining supervised treatment decisions.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Iain Beardsell.