The role of the GP in respiratory health
Respiratory diseases are among the most common long-term conditions affecting patients in the UK. As a GP, your role is to:
- recognise that the identification, assessment, diagnosis and treatment of most acute and chronic respiratory diseases are managed in primary care
- consider how respiratory disease affects patients of all ages. It also brings specific challenges in the diagnosis and treatment of various groups, including children, some occupational and ethnic groups, those with social and mental health challenges and those nearing the end of their life
- be aware of your role as a GP in promoting smoking cessation and offering treatment.
Emerging issues in respiratory health
A wide range of patients with respiratory problems is seen in primary care, which presents challenges for:
- diagnosis: such as distinguishing common minor self-limiting conditions from less common but more serious conditions (for example, sepsis). Early diagnosis is a contributory factor to improving outcomes in conditions such as lung cancer
- awareness of the pros and cons of emerging diagnostic tools such as fractional exhaled nitric oxide (FeNO) in asthma
- recognition: conditions such as chronic obstructive airways disease are under-recognised and contribute significantly to seasonal admissions to secondary care
- recognition: impact of environmental factors and social circumstances, such as air pollution effects and effects of poor damp living conditions on respiratory conditions, especially in children
- patient education: self-management of minor conditions and increasing treatment during exacerbations of chronic conditions such as asthma and chronic obstructive airways disease. Empowering patients with person-centred care
- recognition: impact of Covid and post-Covid syndrome on respiratory symptoms it may present with and the impact it has on patients’ overall wellbeing
- chronic disease management, such as managing recall systems for asthma and chronic obstructive airways disease, the effect on acute admissions and influenza vaccination
- smoking cessation: the value of opportunistic and structured interventions in helping patients stopping smoking and the evolving role of e-cigarettes/vaping in addition to current therapies.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the prevalence and incidence across all ages and any changes over time
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and cultural factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including self-care, initial, emergency and continuing care, chronic disease monitoring
- patient information and education, including self-care
- prognosis.
Symptoms and signs
- Chest pain
- Clubbing
- Collapse
- Cough
- Cyanosis
- Dyspnoea
- Fever
- General malaise, including weight loss and fatigue
- Haemoptysis
- Lymphadenopathy
- Pleural effusion
- Signs of respiratory distress in children (for example, recession, nasal flaring)
- Stridor and hoarseness
- Tachypnoea
- Wheeze
- Peripheral oedema
Common and important conditions
- Asthma: acute and chronic
- Asthma and chronic obstructive pulmonary disease (COPD) overlap
- Bronchiectasis
- COPD
- Connective tissue diseases affecting the lung, such as rheumatoid arthritis, systemic lupus erythematosus (SLE) and sarcoidosis
- Covid-19, including the acute illness, ongoing symptomatic Covid-19 and post-Covid syndrome
- Genetic conditions including cystic fibrosis and alpha-1-antitrypsin deficiency (AATD)
- Immunosuppression affecting the respiratory system, including opportunistic infections such as tuberculosis (TB), fungal and parasitic lower respiratory tract infections (for example, bronchiolitis, bronchitis, pertussis, pneumonia (of any cause), atypical pneumonias including Legionnaire’s disease and tuberculosis), sepsis
- Lower respiratory tract infections
- Lung fibrosis and associated causes, including adverse drug reactions
- Occupational respiratory diseases such as pneumoconioses, asthma, extrinsic allergic alveolitis and asbestos-related disease
- Pleural effusion caused by infection, connective tissue diseases and malignancies
- Pneumothorax, including simple and tension
- Pulmonary embolism
- Respiratory failure and methods of ventilation such as continuous positive airway pressure (CPAP) for sleep apnoea
- Respiratory malignancies, including laryngeal, bronchial and pleural, such as mesothelioma. Primary and secondary lung malignancies and related paraneoplastic syndromes
- Upper respiratory tract infections, including tonsillitis, peritonsillar abscess, epiglottitis, laryngitis, pharyngitis and tracheitis
Examinations and procedures
- Appropriate focused clinical examination to identify respiratory disease
- Specific procedures, such as peak expiratory flow rate measurement
- Demonstrate the correct use of inhalers, including with delivery device (aerochamber or volumatic) and check that a patient can use their device properly
- Administration of inhaled bronchodilators with spacer or nebuliser, including correct techniques
Investigations
- Primary care investigations such as spirometry, exhaled nitric oxide testing (FeNO), pulse oximetry, blood tests and sputum culture (including indications for, correct technique, interpretation of results and factors affecting results)
- Disease scoring tools (such as CRB-65 for community-acquired pneumonia)
- Indications for chest X-rays, computed tomography (CT) and magnetic resonance imaging (MRI) scans
Service issues
- Local and national guidelines to manage common respiratory diseases (asthma, COPD, lung cancer) in primary care
- Indications for the use of oxygen in emergency, acute and chronic management, including domiciliary oxygen and use in palliative care
- Patients’ understanding of prescribed inhaled medication, both routinely and in an emergency, including its appropriate use and technique
- Inhaler devices, including types of device and their ease of use, prescribing, planetary health, cost-effectiveness and patient preference
- Support available to patients and their carers from health, social services and charities/voluntary sector organisations
Additional important content
- History-taking: key points with respect to specific respiratory diseases (for example, in relation to occupation, smoking, ‘red flag’ symptoms, family history)
- The importance of lifestyle changes, particularly smoking cessation, and pulmonary rehabilitation
- The impact of comorbidity, such as muscle wasting, osteoporosis, cardiovascular disease or mental health problems in people with long-term respiratory conditions such as asthma and COPD, and the effect of these on morbidity and mortality
- The potential for financial compensation for those diagnosed with mesothelioma and other occupational lung diseases. Appropriate signposting to specialist services, and appropriate death certification for these conditions
Case discussion
Callum Davies is a 55-year-old man who first presented to you a year ago complaining of increasing breathlessness over the past year. Further discussion revealed repeated winter chest infections with mucopurulent sputum needing antibiotics. He is a smoker, having started smoking age 15. He usually smokes one pack of cigarettes per day. He is a self-employed plumber. His mother has COPD.
He has a body mass index (BMI) of 31. On the basis of an examination and investigations, you diagnosed COPD and prescribed appropriate inhaler devices. You also offered support to stop smoking, follow-up with the practice nurse and a referral for pulmonary rehabilitation at the local community centre.
It is now the following winter and Callum attends an emergency GP appointment. He is distressed, breathless, cyanosed and tachycardic, with an SpO2 (oxygen saturation) of 89%, having been unwell for the previous five days. Although he has stopped smoking his wife continues to do so. He tells you he did not want to bother anyone and cannot afford to take time off work. He had hoped he could ride out this episode using more inhalers.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | What are my personal feelings about smoking-related illnesses and how do I ensure these do not adversely affect the care I provide? |
An ethical approach This is about practising ethically with integrity and a respect for equality and diversity. | Is Callum responsible for his own illness? What are the challenges facing me as a GP in delivering effective care in this case? How does patient autonomy influence joint decision-making (considering occupation, smoking or illicit drug use, which affect respiratory illness and its treatment)? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How could Callum’s worries have been addressed, and by whom? What is the role of self-management in respiratory disease? How can patients be empowered? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What investigations are appropriate to diagnose COPD? How confident am I at interpreting spirometry? How do I grade the severity of symptoms and functionality? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What clinical skills do I need to assess different patients with respiratory disease, including children, older adults and those with mental health problems? What is the correct technique for recording a peak expiratory flow rate and for using a metered-dose inhaler with spacer? How would I instruct my patient to apply these techniques? What are the signs of respiratory distress in a child? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What factors might influence my decisions when assessing or managing patients with respiratory conditions in primary care? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What management options are available for Callum in the acute primary care setting? How can I apply COPD guidance documents to discuss a management strategy with this patient? How can the effectiveness of the treatment be monitored by the patient and by the primary care team? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | What are the common comorbidities associated with respiratory disease? How do comorbidities or systemic problems impact on respiratory illness and its treatment? What impact does the patient’s lifestyle, ethnicity, education and occupation have on their respiratory health and their future treatment? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Are there any local protocols for managing COPD? How are COPD patients looked after in my practice? What role do nurses and other primary care team members play in patients’ management? What is the role of the generalist and the specialist in diagnosis and management? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What is the evidence base for the early identification of patients with chronic lung disease and subsequent health education and therapeutic interventions? Do I know when to introduce additional treatment? How many unidentified patients with COPD are there in our practice? How might we identify such patients? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What templates should I use during consultation with patients with asthma and COPD? How would I monitor quality of care for COPD patients? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | What is the impact of respiratory disease on patients physically, psychologically and socially (including occupation and employability)? What impact does respiratory disease have on families? How do I assess suitability for smoking cessation options? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What is the impact of health and social inequality on respiratory disease prevalence, diagnosis, prognosis and treatment? What support services might be available to Callum and his family? What are the planetary health implications for different inhaler devices? |
How to learn this area of practice
Work-based learning
As a GP registrar, the principal component of your work-based learning around respiratory disease involves discussing, assessing and helping to manage patients with respiratory disease. Learning from the whole multidisciplinary primary care team is important.
Specific learning around the performance and interpretation of lung function testing, as commonly performed in general practice, should reflect the needs and responsibilities of the generalist.
With respect to patients with respiratory disease, a GP should be aware of the roles and responsibilities of the primary care team in its widest sense, including community staff and secondary care outreach, charities and self-help groups, physiotherapists and exercise trainers. You should also look for opportunities to learn from local respiratory consultants, physiotherapists and multidisciplinary groups.
Self-directed learning
You can find eLearning module(s) relevant to this topic guide at elearning for healthcare.
Other organisations offering education and support include: Asthma + Lung UK, the British Society of Allergy and Clinical Immunology (BSACI), British Thoracic Society and Primary Care Respiratory Society (PCRS).
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Interpretation of spirometry results
- Differential diagnosis of breathlessness
- Management of acute and chronic asthma
Simulated Consultation Assessment (SCA)
- A blind woman has recently been diagnosed with asthma and was prescribed salbutamol, but she is still symptomatic
- A carer requests a house visit to an elderly man who has a dry cough and become slightly confused over the past few days
- A man with COPD has been stable on three inhaled medications but is now complaining of increasing cough and dyspnoea
Workplace-based Assessment (WPBA)
- Log entry about your involvement in the asthma clinic and the indications for the different asthma inhalers available
- Consultation Observation Tool (COT) about a woman with a persistent cough whose chest X-ray suggests sarcoidosis
- Audit on the use of high-dose steroid inhalers with reference to current national guidelines